A nurse is assessing a client following a head injury and a brief loss of consciousness. Which of the following findings should the nurse report to the provider?

Edematous bruise on forehead

Glasgow Coma Scale (GCS) score of 14

Pupils are 4 mm and reactive to light

Small drops of clear drainage in the client’s ear

Answer and Explanation

The Correct Answer is D

Choice A reason: An edematous bruise on the forehead is expected after a head injury and, while concerning, is not the most urgent finding. It indicates localized trauma but does not necessarily suggest intracranial complications like cerebrospinal fluid leakage, which poses a greater risk of infection or brain injury.

Choice B reason: A Glasgow Coma Scale score of 14 indicates mild impairment (normal is 15), which is concerning but not the priority. Clear ear drainage suggesting cerebrospinal fluid leak is more urgent, as it indicates a potential skull fracture and risk of meningitis, requiring immediate reporting.

Choice C reason: Pupils that are 4 mm and reactive to light are normal and not immediately concerning. This finding suggests intact cranial nerve function. Clear ear drainage, potentially cerebrospinal fluid, is a more critical sign of skull fracture or brain injury, warranting urgent provider notification.

Choice D reason: Small drops of clear drainage in the ear are highly concerning, as they may indicate cerebrospinal fluid leakage from a basilar skull fracture post-head injury. This poses a risk of meningitis or brain infection, requiring immediate reporting to the provider for diagnostic imaging and intervention.

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Correct Answer is A

Explanation

Choice A reason: Symptoms like jaw, back, and shoulder pain with shortness of breath and nausea suggest a possible myocardial infarction (MI). A 12-lead EKG is the priority to confirm MI by detecting ST-segment changes or Q waves, enabling rapid diagnosis and intervention to restore coronary blood flow and minimize heart damage.

Choice B reason: Administering enteric-coated acetaminophen is inappropriate, as it addresses pain but not the underlying cause of these symptoms, which may indicate an MI. Acetaminophen lacks anti-inflammatory or anti-ischemic properties, and delaying diagnostic measures like an EKG could worsen outcomes in a potential cardiac emergency.

Choice C reason: Obtaining an echocardiogram is not the priority in this acute scenario. While it assesses heart structure and function, it is less urgent than a 12-lead EKG, which quickly diagnoses MI by identifying ischemic changes. Echocardiography may follow later to evaluate complications like wall motion abnormalities.

Choice D reason: Administering ibuprofen is not appropriate, as it does not address the potential MI indicated by these symptoms. Ibuprofen may relieve pain but lacks specificity for cardiac ischemia and could delay critical diagnostic steps like an EKG, risking further myocardial damage in an acute cardiac event.

A. Thrombolytic administration within 10 hrs B. Complete neurologic assessment every 12 hrs C. Alteplase administration within 4.5 hrs D. Vancomycin administration after blood culture

Correct Answer is C

Explanation

Choice A reason: Thrombolytic administration within 10 hours is incorrect, as the therapeutic window for thrombolytics like alteplase in ischemic stroke is typically 3–4.5 hours from symptom onset. Beyond this, the risk of hemorrhage outweighs benefits, making timely administration critical to restore cerebral blood flow and minimize brain damage.

Choice B reason: Completing neurologic assessments every 12 hours is important for monitoring but is not the next action post-CT confirming ischemic stroke. Urgent thrombolytic therapy (e.g., alteplase) within 4.5 hours takes priority to dissolve the clot, restore perfusion, and limit infarct size, improving neurological outcomes.

Choice C reason: Alteplase administration within 4.5 hours is the next step post-CT confirming ischemic stroke. This thrombolytic dissolves the clot obstructing cerebral blood flow, minimizing brain tissue damage. The narrow time window ensures efficacy and reduces hemorrhage risk, making it the priority intervention to improve stroke outcomes.

Choice D reason: Vancomycin administration after blood culture is irrelevant for ischemic stroke, which results from a clot, not infection. Antibiotics like vancomycin treat bacterial infections, not cerebral ischemia. The priority is thrombolytic therapy like alteplase to restore blood flow and prevent further brain tissue damage.

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A nurse is assessing a client following a head injury and a brief loss of consciousness. Which of the following findings should the nurse report to the provider?

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