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 D

Explanation

A. Dimpled area above anus: This can be a sign of a pilonidal cyst, a condition where hair follicles become embedded under the skin.

B. Flap of tissue at sphincter: This could indicate haemorrhoids, swollen veins in the anus and rectum.

C. Hypotonic tone of the anal sphincter: Weak anal sphincter tone can lead to faecal incontinence.

D. Increased pigmentation and coarse skin: This is a normal finding, especially in adults. The perianal area can have a darker colour and thicker skin texture compared to other areas

A. Observe for eye opening to a painful stimulus. B. Ask the client to open his eyes. C. Notify the healthcare provider. D. Check the pupillary response to light.

Correct Answer is B

Explanation

A. Observe for eye opening to a painful stimulus: Using a painful stimulus is part of the Glasgow Coma Scale (GCS) assessment for level of consciousness, providing a systematic way to determine the client's response level. This step should follow if the client does not respond to verbal commands.

B. Ask the client to open his eyes: This is a less invasive step that should be attempted first before applying a painful stimulus. It can provide immediate information about the client's level of consciousness and ability to follow commands.

C. Notify the healthcare provider: Notifying the healthcare provider is essential if the client's condition is critical or worsening. However, it should follow after initial assessment steps have been taken to determine the immediate status.

D. Check the pupillary response to light: Checking pupillary response is important for neurological assessment but does not directly address the need to evaluate the client's response to stimuli, which is critical for assessing consciousness levels.

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Naxlex Comprehensive Predictor Exams

While completing an admission assessment for a client with gastrointestinal bleeding, the nurse inspects the perianal area and anus. Which findings indicate a normal appearance of the anus?

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Correct Answer is B

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