A nurse is caring for a client who sustained a concussion after falling from a ladder. Which of the following interventions should the nurse include in the plan of care? (Select all that apply.)
Monitor the client's Glasgow Coma Scale (GCS) score
Administer acetaminophen for pain relief
Encourage the client to rest in a dark and quiet room
Provide stimulating activities such as puzzles and games
Educate the client about the signs of post-concussion syndrome
Correct Answer : A,B,C,E
Choice A reason:
This is a correct answer. Monitoring the client's GCS score helps to assess the level of consciousness and neurological function after a concussion. The GCS score ranges from 3 to 15, with lower scores indicating more severe brain injury.
Choice B reason:
This is a correct answer. Administering acetaminophen for pain relief helps to reduce headache and discomfort after a concussion. Acetaminophen is preferred over nonsteroidal anti-inflammatory drugs (NSAIDs) or aspirin, which can increase the risk of bleeding.
Choice C reason:
This is a correct answer. Encouraging the client to rest in a dark and quiet room helps to promote healing and recovery after a concussion. Rest includes physical and mental rest, which means avoiding strenuous activities, sports, driving, work, school, or screen time until symptoms resolve.
Choice D reason:
This is an incorrect answer. Providing stimulating activities such as puzzles and games can worsen symptoms and delay recovery after a concussion. The client should avoid cognitive tasks that require concentration, attention, or memory until cleared by a health care provider.
Choice E reason:
This is a correct answer. Educating the client about the signs of post-concussion syndrome helps to prepare them for possible complications and when to seek medical attention. Post-concussion syndrome is a condition in which symptoms persist for weeks or months after a concussion. Symptoms may include headache, dizziness, fatigue, insomnia, anxiety, depression, or cognitive impairment.
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Correct Answer is B
Explanation
Choice A reason:
This is an incorrect answer. Administering antiemetic medication as prescribed is an appropriate action for the nurse to take, but not the first one. The nurse should first assess the client's neurological status, as nausea and vomiting can be signs of increased intracranial pressure (ICP) or worsening brain injury.
Choice B reason:
This is a correct answer. Assessing the client's level of consciousness and orientation is the first action that the nurse should take when caring for a client who has a concussion and reports nausea and vomiting. The nurse should use tools such as the Glasgow Coma Scale (GCS) or the Alert, Verbal, Painful, Unresponsive (AVPU) scale to evaluate the client's neurological function and identify any changes or deterioration.
Choice C reason:
This is an incorrect answer. Providing oral fluids and crackers to the client is not an appropriate action for the nurse to take, especially not the first one. The nurse should avoid giving anything by mouth to the client who has nausea and vomiting, as this can increase the risk of aspiration or dehydration.
Choice D reason:
This is an incorrect answer. Notifying the provider of the client's condition is an important action for the nurse to take, but not the first one. The nurse should first assess the client's neurological status and gather relevant data before reporting to the provider.
Correct Answer is C
Explanation
Choice A reason:
This is an incorrect answer. The nurse should not advise the client to resume their normal activities as long as they wear a helmet. A helmet does not prevent concussions from occurring and may give a false sense of security. The client should not return to sports or other physical activities until they are asymptomatic and cleared by their doctor.
Choice B reason:
This is an incorrect answer. The nurse should not advise the client to avoid any physical activity until their symptoms are completely gone. While the client should avoid strenuous or risky activities that could cause another concussion, they may be able to engage in some light or moderate activities that do not worsen their symptoms or increase their heart rate. The client should follow a gradual return-to-play protocol under the guidance of their doctor.
Choice C reason:
This is a correct answer. The nurse should advise the client to consult their doctor first and follow their recommendations. The doctor will evaluate the client's recovery and determine when it is safe for them to return to sports or other physical activities. The doctor will also provide a gradual return-to-play protocol that involves increasing the intensity and duration of activity over several days or weeks.
Choice D reason:
This is an incorrect answer. The nurse should not advise the client to ask their coach or trainer what they think. The coach or trainer may not be qualified or knowledgeable enough to assess the client's condition and readiness to return to sports or other physical activities. The client should rely on their doctor's advice and not on their coach's or trainer's opinion.
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