A client arrives to the emergency department by ambulance. The client has a possible traumatic brain injury after a fall from a roof. Which of the following assessment findings will the triage nurse report to the provider immediately?

Pupils round, 2mm and constricting to light

Decreasing level of consciousness

Temporal headache

Glasgow coma score of 13

Answer and Explanation

The Correct Answer is B

A.   Pupils round, 2mm and constricting to light is a normal pupil response.
B.   Decreasing level of consciousness is a critical sign of deteriorating neurological status and requires immediate medical intervention.
C.   Temporal headache is a common symptom after head injury but it is not as urgent as a decreasing level of consciousness.
D.   Glasgow coma score of 13 indicates a mild to moderate head injury, but it's a static measurement. A decreasing level of consciousness would indicate worsening condition.

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Correct Answer is A

Explanation

A. Elective cardioversion is a procedure used to restore a normal heart rhythm by delivering a controlled electrical shock to the heart. It is generally used for patients with stable atrial or ventricular arrhythmias who do not respond to medication. In the case of stable VT, elective cardioversion might be considered if the arrhythmia is causing symptoms or if the patient’s condition changes
B. CPR is an emergency procedure used when a person’s heart has stopped beating (cardiac arrest) or when they are not breathing. It is not indicated for a stable VT because the patient is still stable and conscious, and CPR is not used for arrhythmias like VT in a stable patient.
C. Radiofrequency catheter ablation is a procedure used to destroy abnormal electrical pathways in the heart that cause arrhythmias. This is often used as a treatment for recurrent or persistent VT, especially if medication or cardioversion fails to manage the condition effectively. For a stable patient with VT, this treatment might be considered in the long-term management plan rather than as an immediate intervention.
D. Defibrillation is the use of an electrical shock to the heart to restore a normal rhythm in cases of life- threatening arrhythmias such as ventricular fibrillation or pulseless VT. It is not used for stable VT because the patient still has a pulse and is not in immediate danger of cardiac arrest

A. Muscle strength shows no change. B. Muscle contractions become progressively stronger. C. Electrical charge in a muscle increases in intensity. D. A pill-rolling tremor appears.

Correct Answer is B

Explanation

A. If there is no change in muscle strength after the Tensilon test, it indicates a negative result for myasthenia gravis.
B. Muscle contractions become progressively stronger is a positive result for myasthenia gravis. Tensilon temporarily improves muscle strength in patients with this condition.
C. Electrical charge in a muscle increases in intensity is not a relevant parameter for the Tensilon test.
D. A pill-rolling tremor appears is a symptom of Parkinson's disease, not myasthenia gravis.

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A client arrives to the emergency department by ambulance. The client has a possible traumatic brain injury after a fall from a roof. Which of the following assessment findings will the triage nurse report to the provider immediately?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who reports heart palpitations that come and go. An ECG confirms the client is experiencing episodes of ventricular tachycardia (VT). The client is stable. The nurse should anticipate the need for taking which of the following actions?

Correct Answer is A

Explanation

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Correct Answer is B

Explanation

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