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?
The client has a Glasgow Coma Scale (GCS) score of 15
The client has unequal pupils with a difference of 2 mm
The client has a positive Babinski reflex on both feet
The client has difficulty performing finger-to-nose test
The Correct Answer is B
Choice A reason:
This is an incorrect answer. The client does not need immediate reporting if they have a GCS score of 15. This is the highest possible score on the GCS, which indicates that the client is fully alert and oriented.
Choice B reason:
This is a correct answer. The client needs immediate reporting if they have unequal pupils with a difference of 2 mm. This is an abnormal finding that indicates increased intracranial pressure (ICP) or cranial nerve damage, which can be life-threatening.
Choice C reason:
This is an incorrect answer. The client does not need immediate reporting if they have a positive Babinski reflex on both feet. This is a normal finding in infants and young children, but an abnormal finding in adults. However, it does not indicate an acute or urgent condition, but rather a chronic or long-term damage to the corticospinal tract.
Choice D reason:
This is an incorrect answer. The client does not need immediate reporting if they have difficulty performing finger-to-nose test. This is an abnormal finding that indicates cerebellar dysfunction, which affects coordination and balance. However, it does not indicate an acute or urgent condition, but rather a mild or moderate impairment.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C","E"]
Explanation
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.
Correct Answer is C
Explanation
Choice A reason:
This is an incorrect answer. The client does not need further teaching if they say they will take acetaminophen if they have a headache. Acetaminophen is a safe and effective medication for pain relief after a concussion. It does not increase the risk of bleeding or interfere with brain function.
Choice B reason:
This is an incorrect answer. The client does not need further teaching if they say they will avoid drinking alcohol or taking sleeping pills. Alcohol and sleeping pills can worsen the symptoms and recovery of a concussion. They can also mask the signs of worsening brain injury or increase the risk of falls or accidents.
Choice C reason:
This is a correct answer. The client needs further teaching if they say they will check their pupils every hour for any changes. Checking the pupils is not a reliable or accurate way to monitor the condition of a concussion. Pupil changes may not occur until late stages of brain injury or may be caused by other factors such as light exposure or medication use.
Choice D reason:
This is an incorrect answer. The client does not need further teaching if they say they will have someone stay with them for the next 24 hours. Having someone stay with them is a recommended precaution after a concussion. The person can observe the client for any signs of worsening brain injury such as confusion, vomiting, seizures, or loss of consciousness and call for help if needed.
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