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 D

Explanation

A. Heparin can be used to manage DIC but it's not a lifelong treatment and is part of a complex management plan.
B. DIC actually leads to a decreased platelet count due to excessive clotting.
C. DIC is an acquired condition, not a genetic one, and while vitamin K is involved in clotting, it's not the primary cause of DIC.
D. DIC is a complex disorder involving uncontrolled clotting and bleeding due to the depletion of clotting factors, including fibrinogen.

A. Administer prescribed sedatives. B. Instruct the client to perform pursed lip breathing. C. Prepare the client for mechanical ventilation. D. Prepare to administer a vasoconstrictor.

Correct Answer is C

Explanation

A. Sedatives would further depress the respiratory muscles, worsening the myasthenic crisis.
B. Instruct the client to perform pursed lip breathing can be helpful for managing dyspnea in other conditions. However, it's not the priority in a myasthenic crisis where respiratory muscles are rapidly weakening.
C. As respiratory muscles weaken in a myasthenic crisis, the patient is at risk for respiratory failure. Preparing for mechanical ventilation is crucial.
D. A vasoconstrictor is used to treat shock, not a myasthenic crisis.

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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

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