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?

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.

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.