Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is assessing a client who has a concussion from a sports injury. Which of the following manifestations should the nurse expect?
A. Nuchal rigidity
Nuchal rigidity is a sign of meningitis, not concussion.
B. A lingering headache that comes and goes
A lingering headache that comes and goes is a common manifestation of concussion, as the brain tissue is bruised and inflamed.
C. Glasgow Coma Scale score of 11
Glasgow Coma Scale score of 11 indicates moderate brain injury, while concussion is usually mild and does not affect the level of consciousness significantly.
D. Loss of consciousness lasting 30 to 60 min
Loss of consciousness lasting 30 to 60 min is a sign of severe brain injury, not concussion.
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 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.
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.
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.