A nurse is caring for a client admitted with a skull fracture.

Which of the following assessment findings should be of greatest concern to the nurse?

Glasgow Coma Scale score changes from 14 to 9.

WBC count changes from 9,000 to 16,000/mm.

Pulse pressure changes from 30 to 20 mm Hg.

Bilateral pupil diameter changes from 4 to 2 mm.

Answer and Explanation

The Correct Answer is A

A decrease in the Glasgow Coma Scale (GCS) score indicates a decline in the client’s level of consciousness and neurological function.
This can be a sign of increased intracranial pressure or other complications related to the skull fracture.
Choice B is incorrect because an increase in WBC count may indicate an infection, but it is not as concerning as a decrease in GCS score.
Choice C is incorrect because a change in pulse pressure may indicate changes in cardiovascular function, but it is not as concerning as a decrease in GCS score.
Choice D is incorrect because a change in pupil diameter may indicate changes in neurological function, but it is not as concerning as a decrease in GCS score.

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Correct Answer is A

Explanation

This statement indicates an understanding of the teaching because cool, clammy skin is a common symptom of hypoglycemia.
Choice B is incorrect because acetone breath is a symptom of hyperglycemia (high blood sugar), not hypoglycemia (low blood sugar).
Choice C is incorrect because Kussmaul respirations (deep and labored breathing) are a symptom of hyperglycemia, not hypoglycemia.
Choice D is incorrect because increased urine output is a symptom of hyperglycemia, not hypoglycemia.

A. Place pillows under the client's knee. B. Perform range-of-motion exercises on the client's knee. C. Apply an ice pack to the client's knee. D. Gently massage the area around the client's incision.

Correct Answer is C

Explanation

Applying an ice pack can help reduce pain and swelling after total knee arthroplasty.
Placing pillows under the client’s knee (choice A) is not recommended as it can hinder circulation and delay healing.
Performing range-of-motion exercises to the client’s knee (choice B) may be part of the rehabilitation process but should be done under the guidance of a physical therapist and may not be appropriate for immediate pain relief.
Gently massaging the area around the client’s incision (choice D) may not be appropriate as it can cause discomfort and disrupt the healing process.

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A nurse is caring for a client admitted with a skull fracture. Which of the following assessment findings should be of greatest concern to the nurse?

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Naxlex Comprehensive Predictor Exams

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Explanation

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A nurse is caring for a client admitted with a skull fracture.

Which of the following assessment findings should be of greatest concern to the nurse?