A nurse is collecting data from a client who has a traumatic head injury. Which of the following findings should the nurse report to the provider immediately?

Sudden sleepiness

Headache

Diplopia

Slight ataxia

Answer and Explanation

The Correct Answer is A

The nurse should report sudden sleepiness to the provider immediately if the client has a traumatic head injury. Sudden sleepiness can indicate an increase in intracranial pressure, which can be a life-threatening complication of a head injury.

Headache, diplopia, and slight ataxia are also important findings that the nurse should report to the provider. However, these findings are not as urgent as sudden sleepiness. Headache can be a common symptom following a head injury. Diplopia is double vision and can indicate cranial nerve damage. Slight ataxia is unsteadiness or lack of coordination and can indicate neurological damage.

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Correct Answer is D

Explanation

An appropriate conclusion based on this data is that the client opens his eyes when spoken to. A GCS score of 3 for eye opening indicates that the client opens his eyes in response to voice.

The client is not unconscious, as a GCS score of 3 for eye opening indicates that the client is able to open his eyes in response to voice. The client is not unable to make vocal sound, as a GCS score of 5 for best verbal response indicates that the client is able to make vocal sounds. The client may or may not be able to follow simple motor commands, as a GCS score of 5 for best motor response indicates that the client is able to localize pain.

A. Nuchal rigidity B. Batle's sign C. Polyuria D. Lethargy

Correct Answer is D

Explanation

The nurse should monitor the client for lethargy as a manifestation of increased intracranial pressure. Increased intracranial pressure (ICP) is a rise in pressure around the brain that can occur due to various reasons such as brain injury, bleeding into the brain, swelling in the brain, or an increase in cerebrospinal ﬂuid. Lethargy (feeling less alert than usual) is a common symptom of increased ICP.

a. Nuchal rigidity is not a common symptom of increased ICP.
b. Batle's sign is not a common symptom of increased ICP.
c. Polyuria is not a common symptom of increased ICP.

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A nurse is collecting data from a client who has a traumatic head injury. Which of the following findings should the nurse report to the provider immediately?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is receiving a transfer report for a client who has a head injury. The client has a Glasgow Coma Scale (GCS) score of 3 for eye opening, 5 for best verbal response, and 5 for best motor response. Which of the following is an appropriate conclusion based on this data?

Correct Answer is D

Explanation

A nurse is assisting with caring for a client who has a new concussion following a motor-vehicle crash. The nurse should monitor the client for which of the following manifestations of increased intracranial pressure?

Correct Answer is D

Explanation

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