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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. In DIC, there is actually a consumption of clotting factors rather than an increase. The widespread activation of the clotting cascade leads to the consumption of clotting factors and platelets as they are used up in forming numerous small blood clots throughout the body. This depletion results in a paradoxical bleeding tendency due to a shortage of clotting factors.
B. This is characteristic of DIC. The condition involves both excessive clotting (thrombosis) and bleeding. The formation of small clots throughout the microcirculation leads to organ damage and depletion of clotting factors and platelets, which in turn causes bleeding tendencies. This dual process of clot formation and bleeding is a hallmark of DIC.
C. In DIC, there is a decrease in platelet count, not an increase. The condition causes widespread clotting, which consumes platelets rapidly, leading to a low platelet count. Therefore, a progressive increase in platelet count would not be expected in DIC.
D. Sodium and fluid retention are not primary features of DIC. Instead, DIC typically presents with symptoms related to clotting and bleeding rather than fluid balance. Fluid retention would be more associated with other conditions like heart failure or renal disorders, not directly with DIC.
Correct Answer is "{\"xRanges\":[56.64581298828125,96.64581298828125],\"yRanges\":[110.33331298828125,150.33331298828125]}"
Explanation
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