Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A client arrived by EMS after a bar fight. He is disoriented with a Glasgow coma scale of 10.
What additional finding indicates that he has suffered a basilar skull fracture?
A. bruising over the cheek
Bruising over the cheek is a sign of facial trauma, not basilar skull fracture.
B. missing teeth
Missing teeth is a sign of dental injury, not basilar skull fracture.
C. discoloration behind the left ear
Discoloration behind the left ear, also known as Battle's sign, is a sign of basilar skull fracture, as blood accumulates in the mastoid process due to a fracture in the temporal bone.
D. Bleeding from the nose
Bleeding from the nose is a sign of nasal trauma, not basilar skull fracture.
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Full Explanation
Bruising over the cheek is a sign of facial trauma, not basilar skull fracture.
Missing teeth is a sign of dental injury, not basilar skull fracture.
Discoloration behind the left ear, also known as Battle's sign, is a sign of basilar skull fracture, as blood accumulates in the mastoid process due to a fracture in the temporal bone.
Bleeding from the nose is a sign of nasal trauma, not basilar skull fracture.
Similar Questions
A client who suffered a stroke now has functional musculoskeletal deficits and is unable to perform ADLS independently. Which of the following Interventions are appropriate for this client?
A. monitor vital signs
Monitor vital signs. This is not an appropriate intervention for this client because it does not address the functional musculoskeletal deficits or the inability to perform ADLS independently. Monitoring vital signs is a general nursing responsibility that should be done for all clients, but it is not specific to this client's needs.
B. monitor for changes in consciousness
Monitor for changes in consciousness. This is not an appropriate intervention for this client because it does not address the functional musculoskeletal deficits or the inability to perform ADLS independently. Monitoring for changes in consciousness is important for clients who have had a stroke, but it is not the main focus of rehabilitation.
C. assist with range of motion exercises
Assist with range of motion exercises. This is an appropriate intervention for this client because it helps to prevent contractures, maintain joint mobility, and improve muscle strength and coordination. Assisting with range of motion exercises can also promote independence in ADLS by enhancing the client's functional abilities.
D. identify aspiration risks
Identify aspiration risks. This is not an appropriate intervention for this client because it does not address the functional musculoskeletal deficits or the inability to perform ADLSindependently. Identifying aspiration risks is important for clients who have had a stroke,especially if they have dysphagia or facial weakness, but it is not the main focus of rehabilitation.
A nurse at a rehabilitation center is planning care for a client who had a left hemispheric cerebrovascular accident (CVA) 3 weeks ago. Which of the following goals should the nurse include in the client's rehabilitation program?
A. Improve leftside motor function.
Improve leftside motor function. This is not an appropriate goal for this client because it does not match the side of the brain that was affected by the CVA. A left hemispheric CVA causes rightsided weakness or paralysis, so improving rightside motor function would be a more suitable goal.
B. Compensate for loss of depth perception.
Compensate for loss of depth perception. This is not an appropriate goal for this client because it does not match the side of the brain that was affected by the CVA. A left hemispheric CVA causes visual field defects on the right side, such as hemianopia or neglect, socompensating for loss of rightsided vision would be a more suitable goal.
C. Establish the ability to communicate effectively.
Establish the ability to communicate effectively. This is an appropriate goal for this client because it matches the side of the brain that was affected by the CVA. A left hemispheric CVA affects language functions, such as speech, comprehension, reading, and writing, so establishing effective communication is a key goal of rehabilitation.
D. Learn to control impulsive behavior.
Learn to control impulsive behavior. This is not an appropriate goal for this client because it does not match the side of the brain that was affected by the CVA. A left hemispheric CVA causes slow and cautious behavior, so learning to control impulsive behavior would be more suitable for a client who had a right hemispheric CVA.
A nurse is caring for a client who has rightsided acoustic neuroma resulting in impairment of cranial nerves IX and X. Which of the following actions should the nurse take?
A. Apply an eye patch to the client's right eye.
Applying an eye patch to the client's right eye is not indicated for acoustic neuroma, which is a benign tumor of the vestibulocochlear nerve (cranial nerve VIII). This action would not address the impairment of cranial nerves IX and X, which are responsible for swallowing, gagging, and speech. Therefore, this choice is incorrect.
B. Place suction equipment at the client's bedside.
Placing suction equipment at the client's bedside is a correct action for a nurse to take when caring for a client who has impairment of cranial nerves IX and X. These nerves control the pharyngeal and laryngeal muscles, which are involved in swallowing and preventing aspiration.The client is at risk for choking and aspiration due to impaired gag reflex and difficulty swallowing. Therefore, this choice is correct.
C. Avoid the use of warm water to wash the client's face.
Avoiding the use of warm water to wash the client's face is not necessary for a client who has acoustic neuroma or impairment of cranial nerves IX and X. This action would be more appropriate for a client who has trigeminal neuralgia (cranial nerve V), which causes severefacial pain triggered by stimuli such as heat, cold, or touch. Therefore, this choice is incorrect.
D. Provide rangeofmotion exercises to the client's neck and shoulders.
Providing rangeofmotion exercises to the client's neck and shoulders is not directly related to the care of a client who has acoustic neuroma or impairment of cranial nerves IX and X. This action would be more beneficial for a client who has cervical spondylosis or muscle tension that affects the neck and shoulder mobility. Therefore, this choice is incorrect.