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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The glycosylated hemoglobin level (also known as HbA1c or A1C) is a laboratory test that reflects average levels of blood glucose over the previous two to three months.
It is the most widely used test to monitor chronic glycemic management.
Choice A is not the answer because fasting blood glucose level reflects only short-term glycemic control.
Choice C is not the answer because oral glucose tolerance test results reflect only short-term glycemic control.
Choice D is not the answer because postprandial blood glucose level reflects only short-term glycemic control.
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.
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