A nurse has received report on a client who has a basilar skull fracture. Which of the following findings should the nurse anticipate with this client?
Ability to recall how the injury occurred
Pooling of blood and edema around the eyes
Bruising over the mastoid process
Chvostek's sign
Correct Answer : B,C
A. Clients with a basilar skull fracture may experience confusion or memory loss regarding the injury, making them unable to recall how it occurred.
B. Pooling of blood around the eyes, known as "raccoon eyes," is a common sign of a basilar skull fracture.
C. Bruising over the mastoid process (Battle's sign) is another classic sign of a basilar skull fracture, indicating trauma to the base of the skull.
D. Chvostek's sign is associated with hypocalcemia, not basilar skull fractures.
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Correct Answer is D
Explanation
A. Standing with feet close together when lifting an object does not provide adequate support or balance, increasing the risk of injury. Proper body mechanics involve keeping feet apart for a stable base of support.
B. Putting weight on the heels when moving an object is not advised. Instead, one should keep the weight distributed over the whole foot for stability.
C. When pushing an object, stepping forward with the front foot (rather than moving it backward) helps to maintain balance and applies proper force.
D. Facing the direction of movement is a correct application of proper body mechanics, as it prevents twisting of the spine, reduces strain on the back, and promotes safe movement.
Correct Answer is C
Explanation
A. A QRS interval of 0.08 second is within the normal range and does not indicate a myocardial infarction.
B. A PR interval of 0.15 second is normal and not indicative of an acute myocardial infarction.
C. ST-segment elevation above the isoelectric line is a key indicator of an acute myocardial infarction (STEMI), signifying myocardial injury.
D. The QT interval being equal to the R to R interval is not a specific indicator of myocardial infarction.