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.
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Naxlex Comprehensive Predictor Exams
Related Questions
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.
Correct Answer is A
Explanation
A. Tachycardia is a classic sign of the compensatory stage of shock. The body attempts to increase cardiac output by increasing heart rate to maintain blood pressure.
B. Hypokalemia is more likely to occur in the later stages of shock, as it's associated with tissue breakdown and renal dysfunction.
C. Mottled skin is a sign of the progressive stage of shock, indicating poor peripheral perfusion.
D. Blood pressure 115/68 mmHg: While this might be considered within normal range, it's important to consider the baseline blood pressure of the patient. In the compensatory stage, blood pressure may be maintained, but there are other compensatory mechanisms in place (like increased heart rate) to do so.
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