Herbert, a 45 year old construction engineer is brought to the hospital unconscious after falling from a 2-story building. When assessing the client, the nurse would be most concerned if the assessment revealed:

Correct Answer: C

Rationale: The correct answer is C: Bleeding from ears. This finding indicates a potential skull fracture or brain injury, which is a serious concern in a patient who has fallen from a height. Here's the rationale: 1) Reactive pupils (Choice A) are a normal response and indicate intact neurological function. 2) A depressed fontanel (Choice B) is a concern in infants but not in a 45-year-old adult. 3) An elevated temperature (Choice D) can be a sign of infection or inflammation, but in this case, the immediate concern is the potential head injury indicated by bleeding from the ears.

Correct Answer: C

Rationale: Correct Answer: C Rationale: Applying dexamethasone cream in long, even, outward, and downward strokes in the direction of hair growth helps to spread the medication evenly, following the natural skin texture. This method ensures proper absorption and minimizes potential irritation. It also prevents damage to the hair follicles. Summary: A: Circular motion may not evenly distribute the cream, affecting absorption. B: Applying upward may not be suitable for dermatitis and could lead to irritation. D: Applying in the opposite direction of hair growth can cause discomfort and hinder absorption.

Correct Answer: D

Rationale: The correct answer is D: Heparin-associated thrombosis and thrombocytopenia (HATT). Following CABG surgery, patients are at risk for developing HATT due to the use of heparin as anticoagulant. The sudden decrease in platelet count from 230,000 to 5,000 suggests heparin-induced thrombocytopenia (HIT), a condition where the immune system activates platelets in response to heparin, leading to platelet destruction and thrombosis. Pancytopenia (choice A) is a reduction in all blood cell types, not specific to platelets. Idiopathic thrombocytopemic purpura (ITP) (choice B) is an autoimmune disorder characterized by low platelets, but not typically associated with recent surgery. Disseminated intravascular coagulation (DIC) (choice C) involves widespread clotting leading to platelet consumption, but the rapid decrease

Correct Answer: C

Rationale: The correct answer is C: Myxedema coma. Skipping thyroid replacement medication can lead to hypothyroidism worsening, potentially progressing to myxedema coma, a life-threatening condition characterized by extreme hypothyroidism. This can result in decreased consciousness, hypothermia, respiratory depression, and other serious complications. Exophthalmos (choice A) is associated with hyperthyroidism, not skipping thyroid medication. Thyroid storm (choice B) is a severe complication of hyperthyroidism, not hypothyroidism. Tibial myxedema (choice D) is a rare localized form of myxedema, not a life-threatening complication of skipping thyroid replacement therapy.

Correct Answer: B

Rationale: The correct answer is B: A decreased TSH level. In hyperthyroidism, there is an overproduction of thyroid hormones, leading to a negative feedback loop that suppresses the release of TSH from the pituitary gland. Therefore, a decreased TSH level is indicative of hyperthyroidism. Rationale: 1. A: No increase in TSH level after 30 minutes during TSH stimulation test - In hyperthyroidism, the TSH level would already be low, so no increase would be expected. 2. C: An increase in TSH level after 30 minutes during TSH stimulation test - This contradicts the pathophysiology of hyperthyroidism where TSH is suppressed. 3. D: Below-normal levels of serum T3 and T4 - While low T3 and T4 levels can occur in hypothyroidism, in hyperthyroidism, there is typically an excess of these hormones. In summary, a decreased TSH