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
A client reports having a fever, night sweats, and cough for 2 days.
These symptoms are associated with infectious diseases such as tuberculosis.
In order to prevent the spread of infection to other patients, this client would require a private room.
A client with diabetes mellitus and acute ketoacidosis does not require a private room based on their diagnosis.
C)A client with a compound fracture of the right femur does not require a private room based on their diagnosis.
D)An older adult client with aspiration pneumonia does not require a private room based on their diagnosis.
Correct Answer is C
Explanation
“Weight loss of.8 kg (4 Ib) in the past 24 hr.” Furosemide is a diuretic that decreases the pressure caused by excess fluid in the heart and lungs.
A weight loss of.8 kg (4 Ib) in the past 24 hr indicates that excess fluid is being removed from the body, which is a sign that the medication is effective.
Choice A is incorrect because adventitious breath sounds are a symptom of pulmonary edema, not an indication that the medication is effective.
Choice B is incorrect because furosemide has direct vasodilatory outcomes 2, which would decrease blood pressure, not elevate it.
Choice D is incorrect because there is no information found to support this statement.
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