,Leadership & Management Concepts
Priority, Projectile Vomit
Test Id: 54335228
Question Id: 32076 (751847)
4 of 20
A A A
The nurse is managing assigned clients on the evening shift. Which client presentation
is a priority?
Unordered Options Ordered Response
1. Blunt head trauma with projectile vomiting
2. History of Alzheimer disease with agitation
3. History of carpal tunnel syndrome with hand numbness
4. History of third cranial nerve pathology with double vision
You answered this question correctly.
Time Spent: 66 Seconds
95% of people answered this question correctly.
Last Updated: 12/30/2015
Explanation
A client with a traumatic head injury from blunt force can have delayed symptoms if
there is bruising in the brain and subdural hematoma/cerebral edema develops. A
subdural hematoma is typically a slower venous bleed, and symptoms appear 24-48
hours later. Signs and symptoms are similar to those of increased intracranial
,pressure and include change in level of consciousness, projectile vomiting, ataxia,
ipsilateral (unilateral) pupil dilation, and seizures. Brain herniation can occur if the
condition is not recognized and treated.
(Option 2) Neuropsychiatric symptoms such as agitation, aggression, delusions,
hallucinations, wandering, and depression are very common in clients with dementia.
Some may have an underlying etiology (eg, pain, infection) that requires identification
and treatment. This client is the second priority as the condition is not immediately life-
threatening.
(Option 3) Carpal tunnel syndrome is a compression of the median nerve within the
carpal tunnel at the wrist. Clinical manifestations are weakness, pain, numbness, and
impaired sensation in the median nerve distribution. Numbness is an expected
symptom; a splint is worn to relieve the pressure.
(Option 4) The third cranial nerve controls the majority (4/6) of the extraocular
muscles. As a result, the lesion can cause weakness in eye movements with resultant
diplopia, which is an expected finding.
Educational objective:
A client with a head injury and signs of increased intracranial pressure (eg, change in
level of consciousness, projectile vomiting, pupil dilation, ataxia) is a priority.
Leadership & Management Concepts
DIC Priority
Test Id: 54335228
Question Id: 34070 (751847)
6 of 20
A A A
, The nurse is caring for clients on a busy medical-surgical unit. Which client would be
priority to assess first?
Unordered Options Ordered Response
1. A client with an ileostomy bag that has leaked stool all over
A client with chronic obstructive pulmonary disease, diminished
2.
breath sounds, and SpO2 of 91%
A client with deep venous thrombosis who missed the last warfarin
3.
dose
4. A client with sepsis who is developing petechiae
You answered this question correctly.
Time Spent: 189 Seconds
69% of people answered this question correctly.
Last Updated: 2/25/2016
Explanation
Clients with sepsis are at risk for developing disseminated intravascular coagulation
(DIC), a condition that initially causes clotting within the microvessels. Platelets and
clotting factors are consumed in clotting and become unavailable for body use, leading
to bleeding complications. The initial clotting also disrupts blood flow to extremities
and organs.
Signs of DIC include frank external bleeding (eg, venipuncture site bleeding), signs of
internal bleeding (petechiae, ecchymosis, hematuria, hematemesis, and bloody stools),
and respiratory distress (eg, bleeding/clotting into lungs). Signs of DIC need immediate
assessment and emergency intervention. Rapid replacement of clotting factors (fresh
frozen plasma), platelets, and blood is needed to save the client from death.
(Option 1) Stool leaking from an ileostomy bag is not a priority.
(Option 2) It is common for clients with chronic obstructive pulmonary disease to have
diminished breath sounds; the goal SpO2 level in this population is generally ≥90%.
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