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.

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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.

Correct Answer is ["2600"]

Explanation

The total fluid prescribed is 5,200 mL over 24 hours. We need to calculate how much fluid the client will receive in the first 8 hours.

Step-by-Step Calculation:

Step 1: Determine how much fluid is given in the first 8 hours. The rule is that half of the total fluid is administered in the first 8 hours.

Total fluid = 5,200 mL.
Fluid for the first 8 hours = Total fluid ÷ 2.

Write it out:
5,200 ÷ 2 = 2,600.

Result: 2,600 mL.

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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

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 nurse is preparing to start an IV infusion of Lactated Ringer's for a client who sustained a burn injury. The client is prescribed 5,200 mL of fluid over the first 24 hr. How many milliliters of fluid will the client receive in the first 8 hours? Record your answer.

Correct Answer is ["2600"]

Explanation

Step-by-Step Calculation:

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