CORRECT WELL DETAILED
ANSWERS|LATEST
2025/2026|GUARANTEED A+
Which of the following is the earliest and most significant sign of increasing intracranial
pressure (ICP)?
Change in level of consciousness (LOC)
Seizures
Restlessness
Pupil changes - ANSWER Change in level of consciousness (LOC)
Explanation:
The earliest sign of increasing ICP is a change in LOC. Any changes in LOC should be reported
immediately. Seizures, restlessness, and pupil changes may occur, but these are not the
earliest signs.
The ED nurse is receiving a client handoff report at the beginning of the nursing shift. The
departing nurse notes that the client with a head injury shows Battle sign. The incoming
nurse expects which to observe clinical manifestation?
A bloodstain surrounded by a yellowish stain on the head dressing
An area of bruising over the mastoid bone
Escape of cerebrospinal fluid from the client's ear
Escape of cerebrospinal fluid from the client's nose - ANSWER An area of bruising over
the mastoid bone
Explanation:
Fractures of the base of the skull tend to traverse the paranasal sinus of the frontal bone or
the middle ear located in the temporal bone Therefore, they frequently produce
hemorrhage from the nose, pharynx, or ears, and blood may appear under the conjunctiva.
An area of ecchymosis (bruising) may be seen over the mastoid (Battle sign). Basilar skull
fractures are suspected when cerebrospinal fluid (CSF) escapes from the ears (CSF otorrhea)
and the nose (CSF rhinorrhea). Drainage of CSF is a serious problem because meningeal
infection can occur if organisms gain access to the cranial contents via the nose, ear, or sinus
1
, through a tear in the dura. A bloodstain surrounded by a yellowish stain on the head
dressing is referred to as a halo sign and is highly suggestive of a CSF leak.
After a motor vehicle crash, a client is admitted to the medical-surgical unit with a cervical
collar in place. The cervical spinal X-rays haven't been read, so the nurse doesn't know
whether the client has a cervical spinal injury. Until such an injury is ruled out, the nurse
should restrict this client to which position?
Flat
Supine, with the head of the bed elevated 30 degrees
Flat, except for logrolling as needed
A head elevation of 90 degrees to prevent cerebral swelling - ANSWER Flat, except for
logrolling as needed
Explanation:
When caring for the client with a possible cervical spinal injury who's wearing a cervical
collar, the nurse must keep the client flat to decrease mobilization and prevent further injury
to the spinal column. The client can be logrolled, if necessary, with the cervical collar on.
In a spinal cord injury, neurogenic shock develops due to loss of the autonomic nervous
system functioning below the level of the lesion. Which of the following indicators of
neurogenic shock would the nurse expect to find? Select all that apply.
Hypotension
Tachycardia
Venous pooling
Diaphoresis
Tachypnea
Hypothermia - ANSWER Hypotension
Venous pooling
Tachypnea
Hypothermia
Explanation:
2
ANSWERS|LATEST
2025/2026|GUARANTEED A+
Which of the following is the earliest and most significant sign of increasing intracranial
pressure (ICP)?
Change in level of consciousness (LOC)
Seizures
Restlessness
Pupil changes - ANSWER Change in level of consciousness (LOC)
Explanation:
The earliest sign of increasing ICP is a change in LOC. Any changes in LOC should be reported
immediately. Seizures, restlessness, and pupil changes may occur, but these are not the
earliest signs.
The ED nurse is receiving a client handoff report at the beginning of the nursing shift. The
departing nurse notes that the client with a head injury shows Battle sign. The incoming
nurse expects which to observe clinical manifestation?
A bloodstain surrounded by a yellowish stain on the head dressing
An area of bruising over the mastoid bone
Escape of cerebrospinal fluid from the client's ear
Escape of cerebrospinal fluid from the client's nose - ANSWER An area of bruising over
the mastoid bone
Explanation:
Fractures of the base of the skull tend to traverse the paranasal sinus of the frontal bone or
the middle ear located in the temporal bone Therefore, they frequently produce
hemorrhage from the nose, pharynx, or ears, and blood may appear under the conjunctiva.
An area of ecchymosis (bruising) may be seen over the mastoid (Battle sign). Basilar skull
fractures are suspected when cerebrospinal fluid (CSF) escapes from the ears (CSF otorrhea)
and the nose (CSF rhinorrhea). Drainage of CSF is a serious problem because meningeal
infection can occur if organisms gain access to the cranial contents via the nose, ear, or sinus
1
, through a tear in the dura. A bloodstain surrounded by a yellowish stain on the head
dressing is referred to as a halo sign and is highly suggestive of a CSF leak.
After a motor vehicle crash, a client is admitted to the medical-surgical unit with a cervical
collar in place. The cervical spinal X-rays haven't been read, so the nurse doesn't know
whether the client has a cervical spinal injury. Until such an injury is ruled out, the nurse
should restrict this client to which position?
Flat
Supine, with the head of the bed elevated 30 degrees
Flat, except for logrolling as needed
A head elevation of 90 degrees to prevent cerebral swelling - ANSWER Flat, except for
logrolling as needed
Explanation:
When caring for the client with a possible cervical spinal injury who's wearing a cervical
collar, the nurse must keep the client flat to decrease mobilization and prevent further injury
to the spinal column. The client can be logrolled, if necessary, with the cervical collar on.
In a spinal cord injury, neurogenic shock develops due to loss of the autonomic nervous
system functioning below the level of the lesion. Which of the following indicators of
neurogenic shock would the nurse expect to find? Select all that apply.
Hypotension
Tachycardia
Venous pooling
Diaphoresis
Tachypnea
Hypothermia - ANSWER Hypotension
Venous pooling
Tachypnea
Hypothermia
Explanation:
2
