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 A
Explanation
People with diabetes should wear cotton rather than nylon socks.
Cotton socks are more breathable and can help keep feet dry, reducing the risk of infection.
Choice B is not the answer because people with diabetes should never use a heating pad on their feet.
Choice C is not the answer because people with diabetes should avoid walking barefoot, even around the house.
Choice D is not the answer because people with diabetes should wash their feet every day in warm water with mild soap, not hot water and antibacterial soap.
Correct Answer is C
Explanation
Wearing a lead apron can help protect the nurse from radiation exposure while providing care to a client receiving internal radiation therapy.
Choice A is incorrect because visitors may need to limit their contact with the client and follow specific safety precautions.
Choice B is incorrect because a dosimeter film badge is worn by the nurse to measure radiation exposure, not placed on the client’s door.
Choice D is incorrect because the door to the client’s room may need to be kept closed as a safety precaution 2.
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