A nurse in an emergency department is caring for a client who has a closed head injury. Which of the following actions should the nurse take first?

Prepare the client for an MRl of the brain.

Administer mannitol IV bolus to the client.

Determine the client's Glasgow Coma Scale score.

D insert an indwelling urinary catheter for the client.

Answer and Explanation

The Correct Answer is C

The correct answer is choice C. Determine the client’s Glasgow Coma Scale score. This is because the Glasgow Coma Scale (GCS) is a tool to assess the level of consciousness and neurological status of a client who has a closed head injury. The GCS score can help guide the priority of interventions and the need for further diagnostic tests.

Choice A is wrong because an MRI of the brain is not the first action to take for a client who has a closed head injury. An MRI may be indicated later to evaluate the extent of brain damage, but it is not an emergency procedure.

Choice B is wrong because mannitol IV bolus is a medication that reduces intracranial pressure (ICP) by drawing fluid out of the brain tissue. However, mannitol should not be administered before confirming the presence and degree of increased ICP, which can be done by measuring the GCS score and other vital signs.

Choice D is wrong because inserting an indwelling urinary catheter for the client is not the first action to take for a client who has a closed head injury. A urinary catheter may be needed to monitor fluid balance and renal function, but it is not an urgent intervention.

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Correct Answer is D

Explanation

The correct answer is choice D. Shuffling gait. This is because shuffling gait is a common manifestation of pseudoparkinsonism, which is a condition that mimics the symptoms of Parkinson’s disease due to the use of certain medications that block dopamine receptors, such as haloperidol. Pseudoparkinsonism can cause slowed movements, muscle stiffness, tremor, and postural instability.

Choice A. Nonreactive pupils is wrong because this is not a typical feature of pseudoparkinsonism or Parkinson’s disease.

Nonreactive pupils can be caused by other conditions, such as brain injury, drugs, or eye diseases.

Choice B. Serpentine limb movement is wrong because this is a characteristic of tardive dyskinesia, another drug-induced movement disorder that can result from long-term use of dopamine receptor blocking agents. Tardive dyskinesia causes involuntary movements of the face, tongue, and limbs that are often writhing or twisting.

Choice C. Smacking lips is wrong because this is also a sign of tardive dyskinesia, not pseudoparkinsonism. Smacking lips is one of the orofacial movements that can occur in tardive dyskinesia due to abnormal muscle contractions.

A. Nontender, protruding abdomen. B. Head circumference exceeds chest circumference. C. Palpable fontanels. D. Natural loss of deciduous teeth E. undefined

Correct Answer is A

Explanation

Answer and explanation.

The correct answer is choice A. A nontender, protruding abdomen is a normal finding for a 2year-old toddler. This is due to the immature development of the abdominal muscles and the relatively large size of the liver and kidneys in relation to the rest of the body.

Choice B is wrong because the head circumference should be equal to or less than the chest circumference by age 2. A head circumference that exceeds the chest circumference could indicate hydrocephalus or other neurological problems.

Choice C is wrong because the fontanels, or soft spots on the skull, should be closed by age 18 months. Palpable fontanels could indicate dehydration, malnutrition, or congenital disorders.

Choice D is wrong because the natural loss of deciduous teeth, or baby teeth, usually begins around age 6. Premature loss of teeth could indicate dental caries, trauma, or endocrine disorders.

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A nurse in an emergency department is caring for a client who has a closed head injury. Which of the following actions should the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who is taking haloperidol and is experiencing pseudoparkinsonism. Which of the following findings should the nurse document as a manifestation of pseudoparkinsonism?

Correct Answer is D

Explanation

A nurse is assessing a 2-year-old toddler. Which of the following findings should the nurse expect?

Correct Answer is A

Explanation

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