ATI LPN
Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017)
Chapter 68 Questions
Question 1 of 5
The ED nurse is caring for a patient who has been brought in by ambulance after sustaining a fall at home. What physical assessment finding is suggestive of a basilar skull fracture?
Correct Answer: C
Rationale: Bruising over the mastoid (Battle's sign) is a classic indicator of basilar skull fracture. Epistaxis, periorbital edema, and facial numbness are not specific to this injury.
Question 2 of 5
A patient is brought to the trauma center by ambulance after sustaining a high cervical spinal cord injury 1 hours ago. Endotracheal intubation has been deemed necessary and the nurse is preparing to assist. What nursing diagnosis should the nurse associate with this procedure?
Correct Answer: B
Rationale: Intubation in cervical spinal cord injury risks exacerbating the injury if the neck is flexed or extended, making 'risk for injury' the primary concern. Other diagnoses are less directly related to intubation.
Question 3 of 5
A nurse is caring for a critically ill patient with autonomic dysreflexia. What clinical manifestations would the nurse expect in this patient?
Correct Answer: B
Rationale: Autonomic dysreflexia presents with bradycardia, hypertension, headache, sweating, and nasal congestion due to sympathetic stimulation above T6. Other symptoms listed are not characteristic.
Question 4 of 5
The nurse is caring for a patient with increased intracranial pressure (ICP) caused by a traumatic brain injury. Which of the following clinical manifestations would suggest that the patient may be experiencing increased brain compression causing brain stem damage?
Correct Answer: A
Rationale: Hyperthermia indicates brain stem damage due to increased metabolic demands. Bradycardia, rising systolic BP, and rapid respirations are earlier ICP signs, while bradypnea occurs later.
Question 5 of 5
A patient is brought to the ED by her family after falling off the roof. A family member tells the nurse that when the patient fell she was knocked out, but came to and seemed okay. Now she is complaining of a severe headache and not feeling well. The care team suspects an epidural hematoma, prompting the nurse to prepare for which priority intervention?
Correct Answer: C
Rationale: Epidural hematoma is a surgical emergency requiring craniotomy to remove the clot and control bleeding. Anticoagulants are contraindicated, and monitoring or antihypertensives are not priorities.