Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A client admitted after a motor vehicle accident arrives with a Glasgow coma score (GCS) of 14 with a mild headache. 4 hours later, the client's GCS has decreased to 10, and now has a dilated pupil on the left side. Which of the following acute traumatic brain injuries does the nurse suspect the client has suffered?
A. Laceration
reason: This is incorrect because laceration is not an acute traumatic brain injury, but a type of wound that involves tearing or cutting of the skin or other tissues. Laceration can occur as a result of a motor vehicle accident, but it does not cause changes in the GCS or pupil size. The nurse should assess the client's skin for any signs of laceration, such as bleeding, swelling, or infection.
B. Acute subdural hematoma
reason: This is incorrect because acute subdural hematoma is not likely to cause a dilated pupil on the left side. Acute subdural hematoma is a type of traumatic brain injury that involves bleeding between the dura mater and the arachnoid mater, which are two layers of the meninges that cover the brain. An acute subdural hematoma can cause a rapid decrease in the GCS, but it usually causes a dilated pupil on the same side as the injury, not on the opposite side.
C. Intracerebral hemorrhage
reason: This is incorrect because intracerebral hemorrhage is not likely to cause a dilated pupil on the left side. Intracerebral hemorrhage is a type of traumatic brain injury that involves bleeding within the brain tissue itself. Intracerebral hemorrhage can cause a gradual decrease in the GCS, but it usually causes neurological deficits that correspond to the location of the bleeding, such as weakness, numbness, or aphasia, not pupillary changes.
D. Epidural hematoma
reason: This is correct because epidural hematoma can cause a dilated pupil on the left side. Epidural hematoma is a type of traumatic brain injury that involves bleeding between the dura mater and the skull. Epidural hematoma can cause a lucid interval, which is a period of normal consciousness followed by a sudden decrease in the GCS, and a dilated pupil on the opposite side of the injury, due to compression of the third cranial nerve. The nurse should notify the provider immediately and prepare for emergency surgery.
This question is an excerpt from Nurse Dive's nursing test bank - ATI Med Surg Proctored Exam 4. Take the full exam now
Full Explanation
Choice A reason: This is incorrect because laceration is not an acute traumatic brain injury, but a type of wound that involves tearing or cutting of the skin or other tissues. Laceration can occur as a result of a motor vehicle accident, but it does not cause changes in the GCS or pupil size. The nurse should assess the client's skin for any signs of laceration, such as bleeding, swelling, or infection.
Choice B reason: This is incorrect because acute subdural hematoma is not likely to cause a dilated pupil on the left side. Acute subdural hematoma is a type of traumatic brain injury that involves bleeding between the dura mater and the arachnoid mater, which are two layers of the meninges that cover the brain. An acute subdural hematoma can cause a rapid decrease in the GCS, but it usually causes a dilated pupil on the same side as the injury, not on the opposite side.
Choice C reason: This is incorrect because intracerebral hemorrhage is not likely to cause a dilated pupil on the left side. Intracerebral hemorrhage is a type of traumatic brain injury that involves bleeding within the brain tissue itself. Intracerebral hemorrhage can cause a gradual decrease in the GCS, but it usually causes neurological deficits that correspond to the location of the bleeding, such as weakness, numbness, or aphasia, not pupillary changes.
Choice D reason: This is correct because epidural hematoma can cause a dilated pupil on the left side. Epidural hematoma is a type of traumatic brain injury that involves bleeding between the dura mater and the skull. Epidural hematoma can cause a lucid interval, which is a period of normal consciousness followed by a sudden decrease in the GCS, and a dilated pupil on the opposite side of the injury, due to compression of the third cranial nerve. The nurse should notify the provider immediately and prepare for emergency surgery.
Similar Questions
A nurse is teaching a client about the Rinne test. Which of the following client statements indicates an understanding of the teaching?
A. "I will wear earphones during this test."
Reason: This is incorrect because earphones are not used in the Rinne test. The Rinne test compares air conduction and bone conduction of sound using a tuning fork.
B. "Small electrodes are placed on my scalp."
Reason: This is incorrect because electrodes are not used in the Rinne test. Electrodes are used in electroencephalography (EEG), which measures brain activity.
C. "A small probe is placed inside my ear."
Reason: This is incorrect because a probe is not used in the Rinne test. A probe is used in tympanometry, which measures the pressure and mobility of the eardrum.
D. "A tuning fork is placed on my head."
Reason: This is correct because a tuning fork is used in the Rinne test. The tuning fork is placed on the mastoid process behind the ear and then moved near the ear canal to compare the sound perception.
Full Explanation
Choice A Reason: This is incorrect because earphones are not used in the Rinne test. The Rinne test compares air conduction and bone conduction of sound using a tuning fork.
Choice B Reason: This is incorrect because electrodes are not used in the Rinne test. Electrodes are used in electroencephalography (EEG), which measures brain activity.
Choice C Reason: This is incorrect because a probe is not used in the Rinne test. A probe is used in tympanometry, which measures the pressure and mobility of the eardrum.
Choice D Reason: This is correct because a tuning fork is used in the Rinne test. The tuning fork is placed on the mastoid process behind the ear and then moved near the ear canal to compare the sound perception.
It is night time and a client who suffers from dementia is agitated and is having difficulty staying in his bed. Which of the following actions should the nurse take first?
A. Turn off the lights and TV and close the door for privacy
Reason: This is incorrect because turning off the lights and TV and closing the door may increase the client's anxiety and confusion. The nurse should provide adequate lighting and familiar objects to help orient the client.
B. Use one wrist restraint to keep the client safe
Reason: This is incorrect because using restraints may increase the risk of injury, infection, and psychological distress for the client. The nurse should use restraints only as a last resort and with a physician's order.
C. Ask the physician for a sedative
Reason: This is incorrect because asking for a sedative may not address the underlying cause of the agitation. The nurse should use non-pharmacological interventions first, such as calming music, massage, or aromatherapy.
D. Identify if there is a cause for the agitation
Reason: This is correct because identifying the cause of the agitation may help resolve it. The nurse should assess for possible triggers, such as pain, hunger, thirst, infection, or environmental factors.
Full Explanation
Choice A Reason: This is incorrect because turning off the lights and TV and closing the door may increase the client's anxiety and confusion. The nurse should provide adequate lighting and familiar objects to help orient the client.
Choice B Reason: This is incorrect because using restraints may increase the risk of injury, infection, and psychological distress for the client. The nurse should use restraints only as a last resort and with a physician's order.
Choice C Reason: This is incorrect because asking for a sedative may not address the underlying cause of the agitation. The nurse should use non-pharmacological interventions first, such as calming music, massage, or aromatherapy.
Choice D Reason: This is correct because identifying the cause of the agitation may help resolve it. The nurse should assess for possible triggers, such as pain, hunger, thirst, infection, or environmental factors.
A client admitted with an acute exacerbation of Ménière's disease asks the student nurse why he was prescribed diphenhydramine. Which response by the student nurse requires correction by the primary nurse?
A. "Ménière's disease is caused by an allergic response."
Reason: This is incorrect because Ménière's disease is not caused by an allergic response. Ménière's disease is a disorder of the inner ear that causes vertigo, tinnitus, hearing loss, and a feeling of fullness in the ear. The exact cause of Ménière's disease is unknown, but it may be related to fluid imbalance, infection, trauma, or autoimmune reaction.
B. "This medication can help offset the nauseous feeling."
Reason: This is correct because diphenhydramine can help offset the nauseous feeling. Diphenhydramine is an antihistamine that blocks histamine receptors in the brain and inner ear, which can reduce nausea and vomiting associated with vertigo.
C. "Anticholinergics will help you rest."
Reason: This is correct because anticholinergics will help you rest. Anticholinergics are a class of drugs that block acetylcholine receptors in the brain and body, which can have sedative effects and reduce motion sickness. Diphenhydramine has anticholinergic properties.
D. "This medication can help reduce vomiting episodes."
Reason: This is correct because diphenhydramine can help reduce vomiting episodes. As mentioned above, diphenhydramine can reduce nausea and vomiting by blocking histamine receptors in the brain and inner ear.
Full Explanation
Choice A Reason: This is incorrect because Ménière's disease is not caused by an allergic response. Ménière's disease is a disorder of the inner ear that causes vertigo, tinnitus, hearing loss, and a feeling of fullness in the ear. The exact cause of Ménière's disease is unknown, but it may be related to fluid imbalance, infection, trauma, or autoimmune reaction.
Choice B Reason: This is correct because diphenhydramine can help offset the nauseous feeling. Diphenhydramine is an antihistamine that blocks histamine receptors in the brain and inner ear, which can reduce nausea and vomiting associated with vertigo.
Choice C Reason: This is correct because anticholinergics will help you rest. Anticholinergics are a class of drugs that block acetylcholine receptors in the brain and body, which can have sedative effects and reduce motion sickness. Diphenhydramine has anticholinergic properties.
Choice D Reason: This is correct because diphenhydramine can help reduce vomiting episodes. As mentioned above, diphenhydramine can reduce nausea and vomiting by blocking histamine receptors in the brain and inner ear.
