The emergency department nurse is caring for a patient who has been brought in by ambulance after sustaining a fall at home. The patient is exhibiting an altered level of consciousness
Following a skull x-ray, the patient is diagnosed with a basilar skull fracture. Which sign should alert the nurse to this type of fracture?
A) Babinski sign
B) Kernig's sign
C) Battle's sign
D) Brudzinski's sign
Ans: C
Feedback: An area of ecchymosis (bruising) may be seen over the mastoid (Battle's sign) in a basilar skull fracture. A positive Kernig's and positive Brudzinski's sign indicate meningeal irritation. Babinski's sign (reflex) is indicative of CNS disease in the corticospinal tract.
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What statement by the parent of a hospitalized toddler leads the nurse to determine the parent understands a hospitalized toddler's need for transitional objects?
a. "This stuffed animal makes him feel secure." b. "He insisted on bringing this dirty old blanket with him." c. "I'm going to buy him a big stuffed animal from the gift shop." d. "I'd like to get him some toys from the playroom."
The perinatal nurse notes that a newborn does not seem to have an opening inside the anal ring. Which action by the nurse takes priority?
A. Ask the mother how well the infant is eating. B. Assess the abdomen and notify the physician. C. Facilitate laboratory studies for kidney function. D. Reassure the parents that this is a normal deviation.
The nurse is aware that the hepatitis A immunization provides immunity in:
a. 5 days. b. 10 days. c. 15 days. d. 30 days.
In given situations, the nature and degree of reasonable care expected of people providing care may differ depending upon which factor?
1. The individual's status as a professional 2. The individual's sense of ethical responsibility 3. The individual's sense of societal obligations 4. The individual's understanding of the law