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. There can be slight variations in pupil size but the difference described (one pupil enlarged and fixed, the other constricted and reactive to light) is not considered normal.

B. Age-related changes in pupil size typically involve a gradual decrease in pupil size, not a sudden and dramatic difference between the two eyes.
C. Unequal pupil size, especially when one pupil is fixed and dilated, is a classic sign of increased intracranial pressure (ICP), often caused by head trauma.
D. Exposure to light would cause both pupils to constrict, not one to dilate and fix.

A. Pacemaker spikes with each T wave B. Pacemaker spikes before each P wave C. Pacemaker spikes before each QRS complex D. Pacemaker spikes after each QRS complex

Correct Answer is C

Explanation

A. Pacemaker spikes with each T wave indicates a malfunctioning pacemaker.
B. Pacemaker spikes before each P wave would indicate atrial pacing, not ventricular pacing.
C. A ventricular pacemaker stimulates the ventricles to contract, so the pacing spike should precede the QRS complex.
D. Pacemaker spikes after each QRS complex would indicate a malfunctioning pacemaker.

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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 in the emergency department when it is noted the left pupil is enlarged and fixed while the right pupil constricts to 2mm when exposed to light. Which of the following is a possible cause of unequal pupil sizing?

Correct Answer is C

Explanation

A nurse is caring for a client with a ventricular pacemaker who is on ECG monitoring. The nurse understands that the pacemaker is functioning properly when which of the following appears on the monitor strip?

Correct Answer is C

Explanation

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