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
The earliest indication of peritonitis in a patient undergoing peritoneal dialysis is often cloudy dialysis fluid when drained from the body.
Choice B is incorrect because an increased heart rate is not the earliest indication of peritonitis.
Choice C is incorrect because generalized abdominal pain is not the earliest indication of peritonitis.
Choice D is incorrect because fever is not the earliest indication of peritonitis.
Correct Answer is D
Explanation
The nurse should apply new gloves when alternating between wound care sites.
This is to prevent cross-contamination and infection.
Choice A, cleaning the equipment in the client’s room once per week, is not an answer because it is not mentioned in the search results as an intervention for a client with full-thickness burns on the lower extremities.
Choice B, providing a diet of fresh fruits and vegetables for the client, is not an answer because it is not mentioned in the search results as an intervention for a client with full-thickness burns on the lower extremities.
Choice C, limiting visitation time for the client’s children to 40 min per day, is not an answer because it is not mentioned in the search results as an intervention for a client with full-thickness burns on the lower extremities.
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