A client arrives to the emergency department by ambulance. The client has a possible traumatic brain injury after a fall from a roof. Which of the following assessment findings will the triage nurse report to the provider immediately?

Pupils round, 2mm and constricting to light

Decreasing level of consciousness

Temporal headache

Glasgow coma score of 13

Answer and Explanation

The Correct Answer is B

A.   Pupils round, 2mm and constricting to light is a normal pupil response.
B.   Decreasing level of consciousness is a critical sign of deteriorating neurological status and requires immediate medical intervention.
C.   Temporal headache is a common symptom after head injury but it is not as urgent as a decreasing level of consciousness.
D.   Glasgow coma score of 13 indicates a mild to moderate head injury, but it's a static measurement. A decreasing level of consciousness would indicate worsening condition.

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Correct Answer is ["A","B","C"]

Explanation

A. Impaired taste is a common symptom of Bell's palsy due to the involvement of the facial nerve, which carries taste fibers.
B. Pain behind the ear is described as a sharp or aching pain. It is a precursor to facial weakness in many cases.
C. As the facial muscles become weak or paralyzed, it leads to a distorted appearance, such as drooping of the eyelid or mouth.
D. Facial twitching is not a typical symptom of Bell's palsy; instead, the muscles are weakened.
E. Hearing loss is not a typical symptom of Bell's palsy.

A. Ask the client to multi-task. B. Speak to the client about one idea at a time. C. Focus on a single form of communication. D. Limit questions to yes and no answers.

Correct Answer is B

Explanation

A. This would be overwhelming for a client with global aphasia, as they have difficulty processing information.
B. This is the correct approach. Breaking down information into smaller, manageable chunks makes it easier for the client to understand.
C. While consistency is important, limiting communication to one method can be restrictive. It's better to use a variety of techniques (verbal, nonverbal, written, etc.) to support understanding.
D. This can be limiting and frustrating for the client. It's essential to encourage all forms of communication, even if it's difficult.

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A client arrives to the emergency department by ambulance. The client has a possible traumatic brain injury after a fall from a roof. Which of the following assessment findings will the triage nurse report to the provider immediately?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who has Bell's palsy. Which of the following findings should the nurse expect? (Select all that apply)

Correct Answer is ["A","B","C"]

Explanation

A nurse is caring for a client who has global aphasia. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

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