A nurse is teaching the parents of a 12-year-old patient who was diagnosed with a concussion after a fall. Which of the following signs and symptoms should the parents report immediately if observed?

Vision 20/25.

Slight bruising on the forehead.

Occasional yawning during the day.

Short-term memory loss.

Reports of nausea and vomiting.

Blurred vision.

Answer and Explanation

Correct Answer : E,F

A concussion is a mild traumatic brain injury resulting from rapid acceleration-deceleration forces causing neuronal dysfunction, impaired cerebral glucose metabolism, and transient disruption of cortical and brainstem regulation. Deterioration after head injury may indicate evolving intracranial hemorrhage or increased intracranial pressure (ICP) requiring urgent escalation.

Rationale:

A. Vision 20/25 is within normal functional visual acuity limits for a 12-year-old. It does not indicate neurological deterioration or increased ICP. This finding is stable and does not require urgent reporting in post-concussion monitoring.

B. Slight bruising on the forehead reflects superficial soft tissue trauma from the initial impact. It does not indicate intracranial injury progression. External bruising alone without neurological decline is not an emergency warning sign.

C. Occasional yawning may reflect fatigue or post-concussive tiredness due to transient cerebral dysfunction. It is nonspecific and not independently associated with increased ICP or neurological deterioration requiring urgent intervention.

D. Short-term memory loss is a common expected post-concussion symptom due to temporary disruption of hippocampal function. While it should be monitored, it is not an acute red flag unless it is worsening or accompanied by other neurologic signs.

E. Nausea and vomiting are critical warning signs of rising intracranial pressure or possible intracranial bleeding. They suggest worsening cerebral edema or brain irritation and require immediate medical evaluation and escalation of care.

F. Blurred vision indicates possible increased intracranial pressure or cranial nerve involvement affecting visual pathways. This is a neurological red flag suggesting potential deterioration of brain function and requires urgent assessment and prompt intervention.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is []

Explanation

Rationale for Correct Choices

Cardiac Arrest: The client presents with the clinical triad of cardiac arrest: unresponsiveness, apnea (not breathing), and pulselessness. The sudden collapse during physical exertion in a patient with cardiovascular risk factors (hypertension, high cholesterol) is highly suggestive of a primary cardiac event.
Begin CPR: High-quality chest compressions are the immediate priority to maintain systemic perfusion and provide blood flow to the heart and brain until advanced life support or defibrillation is available.
Send someone to retrieve the AED: Early defibrillation is the most critical link in the "Chain of Survival" for witnessed cardiac arrest, as the most common cause in this setting is a shockable rhythm like Ventricular Fibrillation (VF).
Palpate Pulse: Regular pulse checks (limited to 10 seconds) during rhythm analysis are necessary to determine if Return of Spontaneous Circulation (ROSC) has occurred.
Compression Effectiveness: Monitoring the depth (at least 2 inches), rate (100–120/min), and allowing full chest recoil is vital to ensure that the manual pumping of the heart is actually circulating blood.

Rationale for Incorrect Choices

Hypoglycemia: While it can cause loss of consciousness, it does not typically cause a sudden "clutching of the chest" and immediate loss of a pulse in a witnessed collapse.
MVC Trauma: There is no evidence of a Motor Vehicle Collision; this was an atraumatic medical collapse during exercise.
Narcotic Overdose: Typically presents with pinpoint pupils and a slow, shallow respiratory rate (respiratory depression) rather than sudden-onset pulselessness during physical activity.
Administer ordered Pain medication for Angina: The patient is pulseless and unresponsive; oral or standard IV pain medications are contraindicated and useless in a state of circulatory collapse.
Apply Non-Rebreather: Oxygen therapy via mask is ineffective if the patient is not breathing and has no circulation to transport the oxygen. The priority is ventilation (via Bag-Valve-Mask) and compressions.
Apply Icepacks to Reduce Inflammation: This is irrelevant in a life-threatening cardiac emergency.
Administer D50W 12.5mg IVP: This is the treatment for hypoglycemia; there is no evidence the patient is hypoglycemic, and CPR/defibrillation must come first.
Assess for power of attorney / Monitor I&Os / Pain Score: These are non-urgent or impossible tasks (the patient cannot report pain) during an active resuscitation.
Examine Extremities for Fall Injuries: While secondary injuries can occur, checking for broken bones is a lower priority than restoring a pulse (the "C-A-B" sequence).

Correct Answer is "{\"xRanges\":[65.51732772435898,71.92758413461539],\"yRanges\":[79.7202797202797,93.7062937062937]}"

Explanation

The external ear (auricle) is composed of several anatomical landmarks that are important during assessment. The tragus is a small cartilaginous projection located just anterior to the external auditory canal. Applying pressure to the tragus is commonly done to assess for pain, which may indicate conditions such as otitis externa.

Rationale:
A. The tragus is the small, rounded cartilage flap located in front of the ear canal opening. It is the structure pressed during assessment to evaluate for tenderness or pain.

B. The helix is the curved outer rim of the ear that forms the visible outer border of the auricle and is not involved in tragus pressure assessment.

C. The external auditory meatus is the opening of the ear canal leading inward toward the tympanic membrane, not the external cartilage that is palpated.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A nurse is teaching the parents of a 12-year-old patient who was diagnosed with a concussion after a fall. Which of the following signs and symptoms should the parents report immediately if observed?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Patient: David Lee, 58-year-old male Given the above scenario, identify the priority patient condition, the most critical parameters to monitor, and the key interventions to perform.

Correct Answer is []

Explanation

Correct Answer is "{\"xRanges\":[65.51732772435898,71.92758413461539],\"yRanges\":[79.7202797202797,93.7062937062937]}"

Explanation

A nurse is assessing a patient suspected of having hyperthyroidism. Which of the following symptoms would support this diagnosis? (Select all that apply.)

During an assessment, the nurse notes a trachea that is deviated to the client's left side. Which condition is the most critical for the nurse to suspect and prioritize intervention for?

The nurse teaches a patient to perform a breast self-exam (BSE). Which finding does NOT need a follow-up with the patients' health care provider?

The nurse documents tonsils as "3+." What does this mean?

The nurse is teaching a group of women about health-promoting interventions. Which health interventions are most responsible for the decline in cervical cancer rates? Select all that apply.

The nurse notes redness and tenderness at the patient's IV insertion site. What should the nurse do next?

The nurse is preparing to assess a 2 year old child's ears. Which technique is appropriate for visualizing the tympanic membrane?

The kindergarten student tells the school nurse that she can't hear out of her left ear. The nurse inspects the ear canal and sees a bright green object. Which condition does the nurse suspect? Select all that apply.