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 C

Explanation

A. While this is a good safety measure for any client, it doesn't address the specific issue of homonymous hemianopsia.
B. This can be helpful for clients with motor difficulties but does not address the visual impairment.
C. Since the client has a right-sided stroke and homonymous hemianopsia, they will likely miss food on the left side of their tray. Reminding them to scan that area can help prevent them from missing food.
D. While this might seem logical, it doesn't address the underlying issue of the client's visual impairment.

A. Abnormally prominent U wave B. Inverted P wave C. Elevated ST segment D. Wide QRS

Correct Answer is A

Explanation

A. Abnormally prominent U wave is a classic sign of hypokalemia. The U wave is normally small and often hidden by the T wave. When it becomes prominent, it's a strong indicator of low potassium levels.
B. Inverted P wave is more indicative of atrial abnormalities, such as atrial fibrillation.
C. Elevated ST segment is often associated with myocardial ischemia or injury.
D. Wide QRS is more characteristic of conduction disturbances like bundle branch blocks.

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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

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Explanation

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