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 D

Explanation

A. Widening pulse pressure is typically associated with increased cardiac output, which is opposite to what happens in hypovolemic shock.
B. Pulse oximetry 96% is a normal oxygen saturation level and does not indicate shock.
C. Increased deep tendon reflexes is not a typical finding in hypovolemic shock.
D. Increased heart rate is a classic compensatory mechanism in response to decreased blood volume. The body tries to maintain blood pressure by increasing heart rate.

A. Increase in the temperature from 37.5° C (99.5° F) to 38.6° C (101.5° F). B. Decrease in the respiratory rate from 20 to 16/min. C. Increase in the heart rate from 88 to 110/min. D. Decrease in the urinary output from 50 mL to 30 mL per hour.

Correct Answer is C

Explanation

A. A slight increase in temperature is common after surgery and might not necessarily indicate shock.
B. A slight decrease in respiratory rate is not indicative of shock. In fact, as shock progresses, respiratory rate often increases.
C. An increased heart rate is a classic compensatory mechanism in response to decreased blood volume, as the body tries to maintain blood pressure.
D. While a decrease in urinary output can be a sign of impending shock, it's often a later sign. In the early stages, the body prioritizes blood flow to vital organs, and urine output may still be within normal limits.

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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?

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Naxlex Comprehensive Predictor Exams

A nurse in the emergency department is assessing a client who has internal injuries from a car crash. The client is disoriented to time and place, diaphoretic, and his lips are cyanotic. The nurse should anticipate which of the findings as an indication of hypovolemic shock?

Correct Answer is D

Explanation

A nurse is caring for a client who returns to the nursing unit from the recovery room after a sigmoid colon resection for adenocarcinoma. The client had an episode of intraoperative bleeding. Which finding indicates to the nurse that the client may be developing hypovolemic shock?

Correct Answer is C

Explanation

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