Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A client is admitted to the hospital with a traumatic brain injury after his head violently struck a brick wall during a gang fight. Which finding is most important for the nurse to assess further?
A. A scalp laceration oozing blood.
This is a possible sign of TBI but is not necessarily indicative of a life- threatening condition.
B. Dizziness, nausea, and transient confusion.
This is a possible sign of TBI but is not necessarily indicative of a life- threatening condition.
C. Headache rated "8" on a 0-10 scale.
This is a possible sign of TBI but is not necessarily indicative of a life- threatening condition.
D. Serosanguineous nasal drainage.
Serosanguineous nasal drainage (a mixture of blood and clear fluid) may suggest a basilar skull fracture, which is a fracture of the base of the skull that can damage vital structures such as the brainstem, cranial nerves, or major blood vessels. This can lead to serious complications such as meningitis, cerebrospinal fluid leak, or hemorrhage.
This question is an excerpt from Nurse Dive's nursing test bank - Interprofessional Care of the Client and Family Across the Lifespan II Proctored Exam. Take the full exam now
Full Explanation
Choice A rationale: This is a possible sign of TBI but is not necessarily indicative of a life- threatening condition.
Choice B rationale: This is a possible sign of TBI but is not necessarily indicative of a life- threatening condition.
Choice C rationale: This is a possible sign of TBI but is not necessarily indicative of a life- threatening condition.
Choice D rationale: Serosanguineous nasal drainage (a mixture of blood and clear fluid) may suggest a basilar skull fracture, which is a fracture of the base of the skull that can damage vital structures such as the brainstem, cranial nerves, or major blood vessels. This can lead to serious complications such as meningitis, cerebrospinal fluid leak, or hemorrhage.
Similar Questions
A patient who has numbness and weakness of both feet is hospitalized with Guillain- Barré syndrome. The nurse will anticipate that collaborative interventions at this time will include ...
A. intubation and mechanical ventilation.
Intubation and mechanical ventilation may be needed if the respiratory muscles are affected by GBS, but this is not a routine intervention at this stage.
B. IV infusion of (Sandoglobulin).
One of the main treatments of GBS is IV immunoglobulin therapy (IVIG), which involves infusing antibodies from donated blood plasma to block the harmful immune response that damages the nerves. Sandoglobulin is one of the brand names of IVIG used for GBS. IVIG can help shorten the duration and severity of the disease, and improve the recovery rate.
C. administration of methylprednisolone (Solu-Medrol).
Methylprednisolone is a corticosteroid that can reduce inflammation, but it is not recommended for GBS, as it may worsen the condition or increase the risk of infection.
D. insertion of a nasogastric (NG) feeding tube
NG feeding tube may be required if the patient has difficulty swallowing, but this is also not a standard intervention at this time.
Full Explanation
Choice A rationale: Intubation and mechanical ventilation may be needed if the respiratory muscles are affected by GBS, but this is not a routine intervention at this stage.
Choice B rationale: One of the main treatments of GBS is IV immunoglobulin therapy (IVIG), which involves infusing antibodies from donated blood plasma to block the harmful immune response that damages the nerves. Sandoglobulin is one of the brand names of IVIG used for GBS. IVIG can help shorten the duration and severity of the disease, and improve the recovery rate.
Choice C rationale: Methylprednisolone is a corticosteroid that can reduce inflammation, but it is not recommended for GBS, as it may worsen the condition or increase the risk of infection.
Choice D rationale: NG feeding tube may be required if the patient has difficulty swallowing, but this is also not a standard intervention at this time.
What topic should the nurse plan as a priority to teach a 26-year-old patient who has been treated for pelvic inflammatory disease?
A. Use of hormone therapy (HT)
Hormone therapy (HT) is used to treat menopausal symptoms, not PID.
B. Irregularities in the menstrual cycle
Irregularities in the menstrual cycle is not a common complications of PID.
C. Changes in secondary sex characteristics
Changes in secondary sex characteristics is not a common complications of PID.
D. Potential complication of infertility
Pelvic inflammatory disease (PID) is an infection of the female reproductive organs that can cause scarring and damage to the fallopian tubes, ovaries, and uterus. This can lead to ectopic pregnancy, chronic pelvic pain, and infertility.
Full Explanation
Choice A rationale: Hormone therapy (HT) is used to treat menopausal symptoms, not PID.
Choice B rationale: Irregularities in the menstrual cycle is not a common complications of PID.
Choice C rationale: Changes in secondary sex characteristics is not a common complications of PID.
Choice D rationale: Pelvic inflammatory disease (PID) is an infection of the female reproductive organs that can cause scarring and damage to the fallopian tubes, ovaries, and uterus. This can lead to ectopic pregnancy, chronic pelvic pain, and infertility.
A nurse is caring for a client who has benign prostatic hyperplasia (BPH). Which of the following medications should the nurse plan to administer?
A. Fluoxymesterone
Fluoxymesterone is a synthetic forms of testosterone that can worsen BPH by increasing the level of DHT.
B. Danazol
Danazol is a synthetic forms of testosterone that can worsen BPH by increasing the level of DHT.
C. Methyltestosterone
Methyltestosterone is a synthetic forms of testosterone that can worsen BPH by increasing the level of DHT.
D. Finasteride
Finasteride is a medication that inhibits the conversion of testosterone to dihydrotestosterone (DHT), which is a hormone that stimulates the growth of the prostate gland. By reducing the level of DHT, finasteride can shrink the enlarged prostate and improve urinary symptoms in men with benign prostatic hyperplasia (BPH). The other choices are not appropriate for BPH.
Full Explanation
Choice A rationale: Fluoxymesterone is a synthetic forms of testosterone that can worsen BPH by increasing the level of DHT.
Choice B rationale: Danazol is a synthetic forms of testosterone that can worsen BPH by increasing the level of DHT.
Choice C rationale: Methyltestosterone is a synthetic forms of testosterone that can worsen BPH by increasing the level of DHT.
Choice D rationale: Finasteride is a medication that inhibits the conversion of testosterone to dihydrotestosterone (DHT), which is a hormone that stimulates the growth of the prostate gland. By reducing the level of DHT, finasteride can shrink the enlarged prostate and improve urinary symptoms in men with benign prostatic hyperplasia (BPH). The other choices are not appropriate for BPH.
 |