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 B

Explanation

A. A high CVP, not a low CVP, is typically associated with fluid overload.
B. A low CVP indicates decreased fluid volume, which is characteristic of hypovolemia. This is particularly relevant to a patient with multiple traumas who may have significant blood loss.
C. While left ventricular failure can contribute to hemodynamic instability, it's not directly correlated with a low CVP.
D. This would affect the oxygenation status of the blood, rather than the overall blood volume and CVP.

A. The drug is not given to clients who are taking anticoagulant or antiplatelet therapy. B. The drug is given in a bolus over the first 3 minutes followed by a continuous infusion. C. The recommended time for drug administration is within 90 minutes after admission to the emergency department. D. The maximum dosage of the drug, including the bolus, is 120 mg intravenously.

Correct Answer is B

Explanation

A. While there are strict inclusion and exclusion criteria for alteplase administration, this statement is overly broad. There are certain situations where anticoagulant or antiplatelet therapy can be managed to allow for alteplase use.
B. Alteplase is administered as a bolus over 1 minute, followed by an infusion over 60 minutes.
C. While time is critical in stroke treatment, the recommended window for alteplase administration is typically within 3-4.5 hours of symptom onset.
D. The maximum dose of alteplase is actually 0.9 mg/kg, up to a maximum of 90 mg.

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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 evaluating the central venous pressure (CVP) of a client who has sustained multiple traumas. Which of the following interpretations of a low CVP pressure should the nurse make?

Correct Answer is B

Explanation

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Correct Answer is B

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