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.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is A

Explanation

A. This description accurately depicts decorticate posturing. The characteristic feature of decorticate posturing is the flexion of the upper extremities (arms) and the extension of the lower extremities (legs). The internal rotation of the legs is often observed in this posture. This pattern is seen in severe brain damage, particularly involving the corticospinal tract.
B. External rotation of the arms is not characteristic of decorticate posturing. In decorticate posturing, the arms are flexed and positioned close to the body, with internal rotation being more typical. Therefore, this option does not accurately describe decorticate posturing.
C. Extension of the arms is more characteristic of decerebrate posturing rather than decorticate posturing. Decerebrate posturing involves the extension of both the arms and legs. Internal rotation of the arms is not a typical feature of decerebrate posturing, so this choice does not describe decorticate posturing.
D. Extension and external rotation of the arms describe decerebrate posturing rather than decorticate posturing. Decerebrate posturing is characterized by the extension of the arms and legs, not flexion. Therefore, this option does not describe decorticate posturing.

A. Hypotension B. Increased respiratory rate C. Anuria D. Decreased level of consciousness

Correct Answer is B

Explanation

A. This is a late sign of shock. It occurs when the body's compensatory mechanisms fail to maintain blood pressure.
B. This is one of the earliest signs of shock. The body tries to compensate for decreased oxygen delivery by increasing the respiratory rate.
C. This is a very late sign of shock, indicating severe kidney damage due to decreased blood flow.
D. This is also a late sign of shock, occurring when the brain is deprived of oxygen.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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 client is experiencing decorticate posturing. Which assessment finding would the nurse expect to observe in this client?

Correct Answer is A

Explanation

A nurse is caring for a client who is at risk for shock. Which of the following findings is the earliest indicator that this complication is developing?

Correct Answer is B

Explanation

A nurse is evaluating the central venous pressure (CVP) of a client who has sustained multiple traumas. Which of the following interpretations of a low CVP pressure should the nurse make?

A nurse is preparing to administer verapamil by IV bolus to a client who is having cardiac dysrhythmias. For which of the following adverse effects should the nurse monitor when giving this medication?

Exhibits A nurse is providing discharge teaching. Which of the following client statements indicate an understanding of the teaching? Client Statements

A nurse is caring for a client who has a suspected diagnosis of myasthenia gravis. The provider prescribes a Tensilon test. Which of the following findings indicates a positive test?

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?

A nurse is caring for a 73-year-old client in the emergency department (ED). Exhibits It has been identified that the client is in sepsis. Select the 4 actions that the nurse should complete in the first hour to manage sepsis and prevent further complications?

A nurse in a coronary care unit is admitting a client who has had CPR following a cardiac arrest. The client is receiving lidocaine IV at 2 mg/min. When the client asks the nurse why he is receiving that medication, the nurse should explain that it has which of the following actions?

A nurse is teaching a newly licensed nurse about evaluating a cardiac rhythm. Which of the following options should the nurse identify as the P wave in the ECG complex? (You will find hot spots to select in the artwork below. Select only the hot spot that corresponds to your answer.)