A nurse is caring for a client admitted with a skull fracture.
Which of the following assessment findings should be of greatest concern to the nurse?
Glasgow Coma Scale score changes from 14 to 9.
WBC count changes from 9,000 to 16,000/mm.
Pulse pressure changes from 30 to 20 mm Hg.
Bilateral pupil diameter changes from 4 to 2 mm.
The Correct Answer is A
A decrease in the Glasgow Coma Scale (GCS) score indicates a decline in the client’s level of consciousness and neurological function.
This can be a sign of increased intracranial pressure or other complications related to the skull fracture.
Choice B is incorrect because an increase in WBC count may indicate an infection, but it is not as concerning as a decrease in GCS score.
Choice C is incorrect because a change in pulse pressure may indicate changes in cardiovascular function, but it is not as concerning as a decrease in GCS score.
Choice D is incorrect because a change in pupil diameter may indicate changes in neurological function, but it is not as concerning as a decrease in GCS score.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A full-thickness burn injury can result in fluid loss and low blood volume (hypovolemia), which can lead to hypotension.
Choice A, Urinary diuresis, is not the correct answer because it refers to increased production of urine and is not a common symptom of a full-thickness burn injury.
Choice C, Decreased respiratory rate, is not the correct answer because it refers to a decrease in the number of breaths per minute and is not a common symptom of a full-thickness burn injury.
Choice D, Bradycardia, is not the correct answer because it refers to a slow heart rate and is not a common symptom of a full-thickness burn injury.
Correct Answer is C
Explanation
A saw-tooth pattern with an atrial rate of 250 to 400/min is a characteristic finding on a cardiac rhythm strip of a client who has atrial flutter.
Choice A is incorrect because progressively longer PR durations are characteristic of a Mobitz type I second-degree AV block, not atrial flutter.
Choice B is incorrect because undetectable P waves are characteristic of atrial fibrillation, not atrial flutter.
Choice D is incorrect because absent PR intervals with a ventricular rate of 40 to 60/min are characteristic of third-degree AV block, not atrial flutter.
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