A client admitted with an acute exacerbation of Ménière's disease asks the student nurse why he was prescribed diphenhydramine. Which response by the student nurse requires correction by the primary nurse?

Choice A reason: This is incorrect because a drop in heart rate from 74 to 68/min is not a manifestation that requires immediate reporting to the provider. A mild decrease in heart rate can be normal or due to other factors such as medication, sleep, or relaxation. It does not indicate a worsening of brain injury or increased intracranial pressure.

Choice B reason: This is the correct answer because a change in the Glasgow Coma Scale score from 14 to 10 is a manifestation that requires immediate reporting to the provider. The Glasgow Coma Scale is a tool that measures the level of consciousness based on eye-opening, verbal response, and motor responses. A score of 14 indicates mild impairment, while a score of 10 indicates moderate impairment. A decrease in score can indicate deterioration of neurological status and increased intracranial pressure, which can be life-threatening.

Choice C reason: This is incorrect because the headache is not a manifestation that requires immediate reporting to
the provider. Headache is a common symptom of mild TBI and can be managed with analgesics, rest, and hydration. It does not indicate a worsening of brain injury or increased intracranial pressure unless it is severe, persistent, or accompanied by other signs such as vomiting, confusion, or seizures.

Choice D reason: This is incorrect because diplopia is not a manifestation that requires immediate reporting to
the provider. Diplopia means double vision and can be caused by damage to cranial nerves or eye muscles due to TBI. It can be treated with eye patches, glasses, or surgery. It does not indicate a worsening of brain injury or increased intracranial pressure unless it is associated with other symptoms such as blurred vision, loss of vision, or eye pain.

Choice A reason: This is correct because the lesion on the child's head is most likely a hemangioma, which is a benign tumor of blood vessels that appears as a red or purple mark on the skin. Hemangiomas are common in newborns and usually grow during the first year of life, then shrink and fade over several years. The nurse should reassure the client that hemangiomas are harmless and do not require treatment unless they interfere with vision, breathing, or feeding.
Choice B reason: This is incorrect because the lesion on the child's head will not spread, but rather grow and shrink within a limited area. The nurse should not alarm the client by suggesting that the lesion will spread to other parts of the body or become malignant. The nurse should explain that hemangiomas are not contagious or infectious and do not affect the child's overall health or development.
Choice C reason: This is incorrect because the lesion on the child's head is not caused by scarring from the birth process, but rather by abnormal growth of blood vessels in the skin. The nurse should not confuse or misinform the client about the cause of the lesion. The nurse should explain that hemangiomas are not related to trauma, infection, or genetics, but rather to unknown factors that influence blood vessel formation during fetal development.
Choice D reason: This is incorrect because the lesion on the child's head is not a precancerous lesion and does not need a referral to a dermatologist. The nurse should not scare or mislead the client by suggesting that the lesion is a sign of cancer or requires further evaluation or treatment. The nurse should explain that hemangiomas are benign and usually resolve on their own without any complications or sequelae.