A nurse is caring for a client who has a mild traumatic brain injury (TBI). Which of the following manifestations should the nurse immediately report to the provider?

A drop in heart rate from 74 to 68/min.

A change in the Glasgow Coma Scale score from 14 to 10.

Headache.

Diplopia.

Answer and Explanation

The Correct Answer is B

Choice A reason: This is incorrect because a drop in heart rate from 74 to 68/min is not a manifestation that requires immediate reporting to the provider. A mild decrease in heart rate can be normal or due to other factors such as medication, sleep, or relaxation. It does not indicate a worsening of brain injury or increased intracranial pressure.

Choice B reason: This is the correct answer because a change in the Glasgow Coma Scale score from 14 to 10 is a manifestation that requires immediate reporting to the provider. The Glasgow Coma Scale is a tool that measures the level of consciousness based on eye-opening, verbal response, and motor responses. A score of 14 indicates mild impairment, while a score of 10 indicates moderate impairment. A decrease in score can indicate deterioration of neurological status and increased intracranial pressure, which can be life-threatening.

Choice C reason: This is incorrect because the headache is not a manifestation that requires immediate reporting to
the provider. Headache is a common symptom of mild TBI and can be managed with analgesics, rest, and hydration. It does not indicate a worsening of brain injury or increased intracranial pressure unless it is severe, persistent, or accompanied by other signs such as vomiting, confusion, or seizures.

Choice D reason: This is incorrect because diplopia is not a manifestation that requires immediate reporting to
the provider. Diplopia means double vision and can be caused by damage to cranial nerves or eye muscles due to TBI. It can be treated with eye patches, glasses, or surgery. It does not indicate a worsening of brain injury or increased intracranial pressure unless it is associated with other symptoms such as blurred vision, loss of vision, or eye pain.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is B

Explanation

Choice A Reason: A virus is not detected by the KOH test, which is used to diagnose fungal infections of the skin, hair, or nails. A virus can be detected by other tests, such as polymerase chain reaction (PCR) or viral culture.

Choice B Reason: A fungal infection is detected by the KOH test, which dissolves the skin cells and leaves behind the fungal elements that can be seen under a microscope. A fungal infection can cause symptoms such as itching, scaling, redness, or blisters.

Choice C Reason: A bacterial infection is not detected by the KOH test, which is specific for fungi. A bacterial infection can be detected by other tests, such as gram stain or culture.

Choice D Reason: Cancer is not detected by the KOH test, which is not a screening tool for malignancy. Cancer can be detected by other tests, such as biopsy or imaging.

A. Stand next to the client when speaking. B. Guide the client away from background noise. C. Provide a copy of the instructions printed in Braille. D. Repeat any phrases that the client misunderstands.

Correct Answer is ["A","B","D"]

Explanation

Choice A Reason: This is a correct choice. Standing next to the client when speaking is an action that the nurse should plan to take, as it helps the client hear better and see the nurse's facial expressions and lip movements. The nurse should also speak clearly and slowly, use simple words and sentences, and avoid covering their mouth.

Choice B Reason: This is a correct choice. Guiding the client away from background noise is an action that the nurse should plan to take, as it reduces distractions and interference with hearing. The nurse should also choose a well-lit and quiet place for communication and turn off any unnecessary devices or appliances.

Choice C Reason: This is an incorrect choice. Providing a copy of the instructions printed in Braille is not an action that the nurse should plan to take, as it is not helpful for clients with hearing loss. Braille is a system of raised dots that represents letters and numbers for people who are blind or visually impaired. The nurse should provide a copy of the instructions printed in large font or use pictures or diagrams to supplement verbal information.

Choice D Reason: This is a correct choice. Repeating any phrases that the client misunderstands is an action that the nurse should plan to take, as it ensures comprehension and clarification of important information. The nurse should also ask open-ended questions, encourage feedback, and summarize key points at the end of the conversation.

View Question and Answer

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

A nurse is caring for a client who has a mild traumatic brain injury (TBI). Which of the following manifestations should the nurse immediately report to the provider?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The client inquires what the positive result from the potassium hydroxide (KOH) test indicates. Which of the following is an accurate response by the nurse?

Correct Answer is B

Explanation

A nurse is preparing to review discharge instructions with a client who reports having hearing loss. Which of the following actions should the nurse plan to take?

Correct Answer is ["A","B","D"]

Explanation

A client arrives to the clinic after spending the day at the beach. She reports extreme pain and the nurse observes red skin on her face and upper body. There are no blisters present. What degree of burn has the client suffered?

A nurse is caring for a client who has a T-4 spinal cord injury. Which of the following client findings should the nurse identify as an indication the client is at risk for experiencing autonomic dysreflexia?

A nurse is caring for a client who is postoperative from glaucoma surgery in the right eye. Which of the following will the nurse include in the postoperative education to the client? (Select all that apply.)

A nurse caring for a client with acute peritonitis reviews the physician's orders. The orders include an NPO diet, insertion of a nasogastric tube set to low intermittent suction, and IV fluids at 50 mL per hour. When asked why he will need the NG tube, what is the nurse's best reply?

A nurse is caring for a client who has burns to his face, ears, and eyelids. The nurse should identify which of the following is the priority finding to report to the provider?

A nurse is caring for a client who is experiencing Cushing's Triad following a subdural hematoma. Which of the following manifestations will the nurse expect to find? (Select all that apply.)

A client arrives with an upper respiratory infection and complains of otalgia, malaise, and nasal drainage. The client's temperature is 100.7 F. Which of the following will the nurse anticipate providing to the client?

A client who is suffering from an allergic reaction asks the nurse what can be done about the itching. Which of the following will the nurse provide to the client?