The nurse is assessing a teenager recently admitted with a severe concussion from playing football. Which is the most important nursing assessment to detect early signs of a declining condition?

Level of consciousness.

Focal neurological exam.

Body posturing.

Vital signs.

Answer and Explanation

The Correct Answer is A

Choice A reason:

Assessing the level of consciousness is the most important nursing assessment for detecting early signs of a declining condition in a patient with a severe concussion. Changes in consciousness can indicate worsening brain injury or increased intracranial pressure, and prompt recognition is crucial for timely intervention.

Choice B reason:

A focal neurological exam is important but is more specific to identifying localized neurological deficits rather than detecting general deterioration. It is essential but secondary to monitoring the overall level of consciousness.

Choice C reason:

Body posturing can indicate severe brain injury or increased intracranial pressure, but it typically occurs later in the course of deterioration. Early changes in the level of consciousness are more sensitive indicators of a declining condition.

Choice D reason:

Vital signs are important to monitor, but changes in vital signs can occur later in the progression of a declining neurological status. Early detection of changes in the level of consciousness allows for more timely intervention.

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Correct Answer is B

Explanation

Choice A reason:

Administering Heparin to a patient who is already taking Warfarin and experiencing rectal bleeding is not appropriate. Heparin is an anticoagulant, similar to Warfarin, and would not help in reversing the anticoagulant effects of Warfarin. Instead, it could potentially exacerbate the bleeding.

Choice B reason:

Vitamin K is the correct answer because it acts as an antidote to Warfarin. Warfarin works by inhibiting the synthesis of Vitamin K-dependent clotting factors, so administering Vitamin K helps to reverse the effects of Warfarin and promote blood clotting, which is necessary to control the rectal bleeding in this patient.

Choice C reason:

Iron is not the appropriate treatment for rectal bleeding due to Warfarin. While iron supplements can help with anemia (which might result from chronic blood loss), they do not address the immediate need to reverse the anticoagulant effects of Warfarin and stop the active bleeding.

Choice D reason:

Protamine is used to reverse the effects of Heparin, not Warfarin. Therefore, administering Protamine would not be effective in addressing the Warfarin-induced rectal bleeding in this patient.

A. Complete a Glasgow Coma Scale assessment. B. Apply pressure to any areas of uncontrolled bleeding. C. Place an indwelling Foley catheter to monitor urine output.

Correct Answer is B,A,C

Explanation

Choice A reason:

Completing a Glasgow Coma Scale assessment is crucial in evaluating the neurological status of a patient with a suspected traumatic cervical spine injury. However, it should be done after ensuring that there is no uncontrolled bleeding.

Choice B reason:

Applying pressure to any areas of uncontrolled bleeding is the highest priority. Controlling bleeding is essential to prevent hypovolemic shock and maintain hemodynamic stability, which takes precedence over other assessments and interventions.

Choice C reason:

Placing an indwelling Foley catheter to monitor urine output is important for ongoing assessment of renal function and fluid balance. However, it is not the immediate priority compared to controlling bleeding and assessing neurological status.

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The nurse is assessing a teenager recently admitted with a severe concussion from playing football. Which is the most important nursing assessment to detect early signs of a declining condition?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in the ED is assessing a client who is taking warfarin and experiencing rectal bleeding. Which of the following drugs should the nurse anticipate administering to the client?

Correct Answer is B

Explanation

The nurse is assessing a patient with suspected traumatic cervical spine injury who just arrived to the emergency department. The nurse knows the priority actions for caring for this patient include all of the following. Place the actions in order of priority.

Correct Answer is B,A,C

Explanation

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