The nurse has received a status report on the following patients admitted with head injuries, which patient should the nurse assess first?

Correct Answer: D

Rationale: The correct answer is D because an unresponsive and dilated pupil (10 mm) can indicate a serious condition like brain herniation, which requires immediate medical attention to prevent further damage. Assessing this patient first is crucial to ensure prompt intervention. - Choice A: A linear skull fracture may require observation but does not indicate an immediate life-threatening condition. - Choice B: Clear leakage from the nose after cranial surgery suggests a CSF leak, which is important but not as urgent as an unresponsive pupil. - Choice C: Losing consciousness for a few minutes after a fall could indicate a concussion, which is concerning but less urgent than a dilated unresponsive pupil.

Correct Answer: D

Rationale: The correct answer is D because a symmetrical stride length indicates a normal gait. When both legs move in a coordinated manner and cover equal distances, it suggests proper balance and coordination. Absent arm swing (A) can indicate a gait abnormality. A narrow base of support (B) can lead to instability. Unequal step lengths (C) can also point to an abnormal gait pattern. In summary, a symmetrical stride length is crucial for an individual to maintain balance and walk efficiently.

Correct Answer: B

Rationale: The correct answer is B because asking the patient what they had for breakfast this morning evaluates their recent memory. This question assesses the patient's ability to recall a specific event from the same day, testing their short-term memory. Choices A, C, and D do not focus on recent memory. Choice A tests long-term memory, choice C assesses immediate memory, and choice D evaluates remote memory. Therefore, B is the best question to evaluate recent memory.

Correct Answer: A

Rationale: The Romberg test is primarily performed to evaluate balance and coordination by assessing the proprioceptive function of the lower extremities. This test helps identify sensory ataxia, a condition where there is a loss of proprioception leading to impaired balance. Testing cranial nerve function (Choice B) involves different assessments, such as cranial nerve examination. Muscle strength (Choice C) is evaluated through manual muscle testing, not the Romberg test. Reflexes (Choice D) are typically assessed using tests like deep tendon reflexes, not the Romberg test. Thus, the correct answer is A as it aligns with the purpose and methodology of the Romberg test.

Correct Answer: D

Rationale: The correct answer is D because a positive Babinski sign in an adult indicates an abnormal response suggesting potential neurological dysfunction, specifically upper motor neuron pathology. This finding is concerning as it can indicate underlying issues such as spinal cord injury, brain tumor, or multiple sclerosis. In contrast, choices A and B are normal findings, indicating proper pupil response and equal strength, respectively. Choice C also indicates normal mental status. So, a positive Babinski sign is the most concerning because it suggests potential serious neurological issues, while the other choices are within normal parameters.