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

Answer and Explanation

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.

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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. Return to work or school as soon as possible B. Avoid driving or operating machinery until cleared by the provider C. Resume sports or physical activities within a week D. Take ibuprofen or aspirin for pain relief

Correct Answer is B

Explanation

Choice A reason:

This is an incorrect answer. The nurse should not instruct the client to return to work or school as soon as possible after a concussion. The client should rest and avoid cognitive tasks that require concentration, attention, or memory until their symptoms resolve and they are cleared by their provider.

Choice B reason:

This is a correct answer. The nurse should instruct the client to avoid driving or operating machinery until cleared by the provider after a concussion. Driving or operating machinery can be dangerous and impairing for the client who may have symptoms such as headache, dizziness, fatigue, blurred vision, or slowed reaction time.

Choice C reason:

This is an incorrect answer. The nurse should not instruct the client to resume sports or physical activities within a week after a concussion. The client should avoid strenuous or risky activities that could cause another concussion or worsen their symptoms until they are asymptomatic and cleared by their provider.

Choice D reason:

This is an incorrect answer. The nurse should not instruct the client to take ibuprofen or aspirin for pain relief after a concussion. Ibuprofen and aspirin are nonsteroidal anti-inflammatory drugs (NSAIDs) that can increase the risk of bleeding in the brain or interfere with blood clotting.

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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?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Correct Answer is B

Explanation

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