An older client presents to the emergency department 3 days after a minor motor vehicle collision (MVC) with an airbag deployment. The client reports a new onset of confusion and nausea. Which assessment warrants immediate intervention by the nurse?Reference Range: Glucose [Reference Range: 0 to 50 years: less than 140 mg/dL or less than 7.8 mmol/L)

Description of head pain.

Concentrated urine output.

Bruising on both arms.

Blood glucose is 160 mg/dL (8.88 mmol/L).

Answer and Explanation

The Correct Answer is D

A Description of head pain: While head pain can be a concern after an MVC, it doesn't necessarily require immediate intervention based on the information provided.

B. Concentrated urine output: Concentrated urine can suggest dehydration, but it's not the most urgent finding in this scenario.

C. Bruising on both arms: Bruising is a common consequence of an MVC and doesn't require immediate intervention.

D. Blood glucose is 160 mg/dL (8.88 mmol/L): This blood sugar level is above the normal reference range and could indicate hyperglycaemia (high blood sugar). In an older adult, especially after a stressful event like an MVC, it's crucial to address this as it can worsen confusion and other symptoms.

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Correct Answer is B

Explanation

A. Documenting asymmetrical thoracic movement: While this might be a finding, it's not the most urgent action.

B. Assist the client to a position that helps the client breathe more easily. Sternocleidomastoid, trapezius, and abdominal muscle use: These muscles are accessory muscles that help with breathing when the diaphragm and intercostal muscles (primary muscles of respiration) are not functioning optimally. This use suggests laboured breathing. Priority action: The client's respiratory distress is the most pressing concern.

C. Incentive spirometer: This device helps improve lung expansion but is not the first-line intervention in this situation where the client is already struggling to breathe.

D. Encouraging deep breaths: This might further strain the respiratory muscles.

A. Description of head pain. B. Concentrated urine output. C. Bruising on both arms. D. Blood glucose is 160 mg/dL (8.88 mmol/L).

Correct Answer is D

Explanation

A Description of head pain: While head pain can be a concern after an MVC, it doesn't necessarily require immediate intervention based on the information provided.

B. Concentrated urine output: Concentrated urine can suggest dehydration, but it's not the most urgent finding in this scenario.

C. Bruising on both arms: Bruising is a common consequence of an MVC and doesn't require immediate intervention.

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Naxlex Comprehensive Predictor Exams

While counting the respirations of an adult client who is bedfast, the nurse observes that the client uses the sternocleidomastoid, trapezius, and abdominal muscles during respirations. Which action should the nurse take in response to this finding?

Correct Answer is B

Explanation

Correct Answer is D

Explanation

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