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. "Yes, you can resume your normal activities as long as you wear a helmet." B. "No, you should avoid any physical activity until your symptoms are completely gone." C. "Maybe, you should consult your doctor first and follow their recommendations." D. "I don't know, you should ask your coach or trainer what they think."

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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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

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Correct Answer is C

Explanation

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