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
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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Related Questions
Correct Answer is C
Explanation
A. This client is at risk for other complications such as electrolyte imbalances or heart failure, but not specifically neurogenic shock.
B. This client is experiencing respiratory distress, which is a different type of shock (anaphylactic or septic shock might be considered, but not neurogenic).
C. Guillain-Barré syndrome is an autoimmune disorder that affects the nervous system, often leading to paralysis. It can cause a rapid loss of muscle function, which can result in neurogenic shock due to loss of sympathetic nervous system tone.
D. This client is at risk for hypovolemic shock due to fluid loss, not neurogenic shock.
Correct Answer is B
Explanation
A. Cryoprecipitates are primarily used to treat bleeding disorders and conditions such as hemophilia or fibrinogen deficiencies. They are not the first-line treatment for hypovolemic shock, which is generally due to significant blood or fluid loss rather than clotting deficiencies.
B. Packed RBCs are a critical component in the management of hypovolemic shock, especially when the shock is due to significant blood loss. Administering packed RBCs helps restore the blood volume and improve oxygen delivery to tissues. This is particularly important in cases where the patient has lost a large volume of blood due to trauma, surgery, or other causes.
C. Albumin is used to treat hypovolemic shock when there is a need to increase intravascular volume due to fluid loss that results in low oncotic pressure. It is particularly useful in cases of burns, liver disease, or other conditions where fluid leaks into the interstitial space. While it can be used to manage hypovolemic shock, packed RBCs are typically the primary choice for blood loss.
D. Platelets are used to treat bleeding disorders where there is a deficiency in platelet count or function, such as in thrombocytopenia or during chemotherapy. They are not typically used for hypovolemic shock unless the shock is complicated by severe bleeding and platelet dysfunction.
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