Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse in the emergency department is caring for a client following an automobile crash in which the client was unrestrained and thrown from the vehicle. When assessing the client, the nurse observes clear fluid draining from the client's nose. Which of the following interventions should the nurse take?
A. Allow the drainage to drip onto a sterile gauze pad.
This is correct because clear fluid draining from the nose could indicate a cerebrospinal fluid (CSF) leak, which is a serious complication of head trauma. Allowing the drainage to drip onto a sterile gauze pad can help confirm the presence of CSF by observing a halo sign (a yellow ring around a blood spot). It also prevents contamination and infection of the CSF.
B. Obtain a culture of the specimen using sterile swabs
This is incorrect because obtaining a culture of the specimen is not a priority intervention for a client with suspected CSF leak. It could also introduce bacteria into the CSF and causemeningitis.
C. Suction the nose gently with a bulb syringe.
This is incorrect because suctioning the nose could increase intracranial pressure and worsen the CSF leak. It could also damage the nasal mucosa and cause bleeding.
D. Insert sterile packing into the nares.
This is incorrect because inserting sterile packing into the nares could obstruct the drainage of CSF and increase intracranial pressure. It could also cause pressure necrosis of the nasal tissue.
This question is an excerpt from Nurse Dive's nursing test bank - Ati med surg adult care 2 proctored exam. Take the full exam now
Similar Questions
A client newly diagnosed with multiple sclerosis is receiving education about newly prescribed medications from the nurse. Which of the following will be included in the client teaching?
A. Beta blockers are used to treat hypertension.
This is incorrect because beta blockers are not used to treat multiple sclerosis. They are used to treat hypertension, angina, arrhythmias, and other cardiovascular conditions.
B. Antispasmodics are used to treat urinary constipation.
This is incorrect because antispasmodics are not used to treat urinary constipation. They are used to treat urinary frequency, urgency, and incontinence, which are common symptoms ofmultiple sclerosis.
C. Corticosteroids are used to put the disease process into remission.
This is incorrect because corticosteroids are not used to put the disease process into remission.They are used to reduce inflammation and edema during acute exacerbations of multiple sclerosis.
D. Immunomodulators are used to prevent relapses.
This is correct because immunomodulators are used to prevent relapses and slow down the progression of multiple sclerosis. They work by modifying the immune system's response to myelin, which is damaged in multiple sclerosis.
After performing a neurological assessment, the student nurse shares the following findings with the primary nurse: Visual fields full to confrontation with Intact extraocular movements. No nystagmus, midline protrusion of tongue, and negative Romberg test. Which of the following will the primary nurse tell the student nurse to document?
A. Abnormal visual fields, abnormal motor assessment
This choice is incorrect because the visual fields and motor assessment are normal, not abnormal.
B. Normal neurological assessment findings
This choice is correct because the findings indicate that the visual fields, extraocularmovements, cranial nerves IX and XII (glossopharyngeal and hypoglossal), and vestibular function are normal.
C. Normal visual but abnormal cranial nerves IXII
This choice is incorrect because the cranial nerves IXII are not assessed in this scenario, only IX and XII are.
D. Normal visual fields, abnormal motor assessment
This choice is incorrect because the motor assessment is normal, not abnormal.
A nurse is assessing a client who has a score of 6 on the Glasgow Coma Scale. The nurse should expect which of the following outcomes based on this score?
A. The client needs total nursing care.
Correct. A score of 6 on the Glasgow Coma Scale indicates severe brain injury and coma.The client would need total nursing care and close monitoring of vital signs, neurologic status, and intracranial pressure.
B. The client has a stable neurologic status
Incorrect. A score of 6 on the Glasgow Coma Scale indicates severe brain injury and coma. The client would not have a stable neurologic status and would be at risk forcomplications such as increased intracranial pressure, seizures, and brain herniation.
C. The client is alert and oriented.
Incorrect. A score of 6 on the Glasgow Coma Scale indicates severe brain injury and coma. The client would not be alert and oriented, but unresponsive to most stimuli.
D. The client has a mild brain injury but requires extensive care
Incorrect. A score of 6 on the Glasgow Coma Scale indicates severe brain injury and coma. The client would not have a mild brain injury, but a lifethreatening condition that requires intensive care.