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

Answer and Explanation

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 D

Explanation

Choice A reason:

This is a correct answer. Frequent headaches are a common symptom of CTE, which is a progressive degenerative brain disease caused by repeated head trauma. Headaches may be triggered by physical or mental exertion, stress, or noise.

Choice B reason:

This is a correct answer. Memory loss is another common symptom of CTE, which affects the areas of the brain responsible for learning and recall. Memory loss may manifest as difficulty remembering names, dates, events, or conversations.

Choice C reason:

This is a correct answer. Personality changes are also a common symptom of CTE, which affects the areas of the brain responsible for mood and behavior. Personality changes may include irritability, aggression, depression, anxiety, impulsivity, or apathy.

Choice D reason:

This is a correct answer. All of the above are possible symptoms of CTE, which can vary in severity and onset depending on the individual and the extent of brain damage. Other possible symptoms include confusion, cognitive impairment, speech problems, vision problems, balance problems, motor problems, or suicidal thoughts.

A. Administer antiemetic medication as prescribed B. Assess the client's level of consciousness and orientation C. Provide oral fluids and crackers to the client D. Notify the provider of the client's condition

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.

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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.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who has a history of multiple concussions. Which of the following findings should alert the nurse to the possibility of chronic traumatic encephalopathy (CTE)?

Correct Answer is D

Explanation

A nurse is caring for a client who has a concussion and reports nausea and vomiting. Which of the following actions should the nurse take first?

Correct Answer is B

Explanation

A nurse is reviewing discharge instructions with a client who had a concussion two days ago. The client says to the nurse, "I feel fine now. Can I go back to playing soccer tomorrow?" How should the nurse respond?

A nurse is providing education to a group of high school athletes about concussion prevention and management. Which of the following information should the nurse include in the teaching? (Select all that apply.)

A nurse is evaluating the effectiveness of the education provided to a client who had a concussion. Which of the following statements by the client indicates a need for further teaching?

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.)

A nurse is preparing to discharge a client who had a concussion from the emergency department. Which of the following instructions should the nurse include in the discharge teaching?

A nurse is performing a neurological assessment on a client who has a concussion. Which of the following findings should the nurse report to the provider immediately?