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

First-degree heart block is a type of atrioventricular (AV) block that involves the consistent prolongation of the PR interval (defined as >0.20 seconds) due to delayed conduction via the atrioventricular node.
This is seen on an ECG as a PR interval greater than 200 ms in length.
Choice B: Nondiscernible P waves are not an answer because it is not mentioned as a characteristic of first-degree heart block in my sources.
Choice C: More P waves than QRS complexes is not an answer because it is not mentioned as a characteristic of first-degree heart block in my sources.
Choice D: No correlation between P and QRS waves is not an answer because it is not mentioned as a characteristic of first-degree heart block in my sources.

A. Implement airborne precautions. B. Determine the client's blood type. C. Institute bleeding precautions. D. Avoid administering IV pain medication.

Correct Answer is C

Explanation

The nurse should institute bleeding precautions for the client.

Petechiae are small red or purple spots on the skin caused by broken capillaries, which can be a sign of low platelet count (thrombocytopenia) and an increased risk of bleeding.
Bleeding precautions include measures such as using a soft-bristled toothbrush, avoiding injections, and avoiding activities that could result in injury.
Choice A is incorrect because airborne precautions are used to prevent the spread of infectious diseases that are transmitted through the air, and are not necessary in this situation.
Choice B is incorrect because determining the client’s blood type is not necessary in this situation.
Choice D is incorrect because avoiding IV pain medication is not necessary in this situation; however, the nurse should monitor the client for signs of bleeding and bruising.

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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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Correct Answer is C

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?