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 {"xRanges":[101.765625,141.765625],"yRanges":[263.609375,303.609375]}
Explanation
A pericardial friction rub is highly specific for acute pericarditis and is generally heard over the left sternal border.
It is often louder at inspiration but sometimes can be better heard on forced expiration while the patient bends forward.
Choice A is not the answer because it does not correspond to the left sternal border.
Choice B is not the answer because it does not correspond to the left sternal border.
Choice D is not the answer because it does not correspond to the left sternal border.
Correct Answer is C
Explanation
This statement indicates an understanding of the teaching because it shows that the client is aware of the importance of reducing their risk of infection by taking precautions when handling pet waste.
Choice A is wrong because while increasing the amount of fresh fruits and vegetables consumed is a healthy dietary choice, it does not demonstrate an understanding of the discharge teaching for a client with AIDS.
Choice B is wrong because while cleaning up areas soiled with body fluids is important, using alcohol and immediately disposing of the trash is not necessary.
Choice D is wrong because taking clothes to the dry cleaners to sterilize them is not necessary for a client with AIDS.
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