A nurse is caring for a client diagnosed with an inner ear infection. Which of the following manifestations will the nurse expect the client to report?

Choice A reason: This is incorrect because a drop in heart rate from 74 to 68/min is not a manifestation that requires immediate reporting to the provider. A mild decrease in heart rate can be normal or due to other factors such as medication, sleep, or relaxation. It does not indicate a worsening of brain injury or increased intracranial pressure.

Choice B reason: This is the correct answer because a change in the Glasgow Coma Scale score from 14 to 10 is a manifestation that requires immediate reporting to the provider. The Glasgow Coma Scale is a tool that measures the level of consciousness based on eye-opening, verbal response, and motor responses. A score of 14 indicates mild impairment, while a score of 10 indicates moderate impairment. A decrease in score can indicate deterioration of neurological status and increased intracranial pressure, which can be life-threatening.

Choice C reason: This is incorrect because the headache is not a manifestation that requires immediate reporting to
the provider. Headache is a common symptom of mild TBI and can be managed with analgesics, rest, and hydration. It does not indicate a worsening of brain injury or increased intracranial pressure unless it is severe, persistent, or accompanied by other signs such as vomiting, confusion, or seizures.

Choice D reason: This is incorrect because diplopia is not a manifestation that requires immediate reporting to
the provider. Diplopia means double vision and can be caused by damage to cranial nerves or eye muscles due to TBI. It can be treated with eye patches, glasses, or surgery. It does not indicate a worsening of brain injury or increased intracranial pressure unless it is associated with other symptoms such as blurred vision, loss of vision, or eye pain.

Choice A Reason: This is correct because first degree burns are superficial burns that affect only the outer layer of the skin, called the epidermis. First degree burns cause redness, pain, and mild swelling, but no blisters or scarring. They usually heal within a week.

Choice B Reason: This is incorrect because second degree burns are partial thickness burns that affect both the epidermis and the underlying layer of the skin, called the dermis. Second degree burns cause blisters, severe pain, and possible infection. They may take several weeks to heal and may leave scars.

Choice C Reason: This is incorrect because third degree burns are full thickness burns that destroy all layers of the skin and may damage the underlying tissues, such as muscles, nerves, or bones. Third degree burns cause charred or white skin, numbness, and shock. They require skin grafting and may cause permanent disability or death.

Choice D Reason: This is incorrect because this burn can be classified according to the depth and extent of the skin damage. The classification of burns helps to determine the appropriate treatment and prognosis for the client.