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 A

Explanation

A. Demonstrates startle reflex: The startle reflex (Moro reflex) typically disappears around 3-4 months of age. If a 6-month-old still demonstrates this reflex, it may indicate a developmental delay or neurological issue, requiring further evaluation.

B. Has doubled birth weight: Doubling of birth weight by 6 months is a normal developmental milestone. This response does not require further evaluation as it indicates appropriate growth.

C. Turns head to locate sound: Turning the head to locate sounds is expected at this age and demonstrates normal auditory and neurological development. This response does not require further evaluation.

D. Plays "peek a boo": Playing "peek a boo" is a typical social interaction for a 6-month-old and indicates normal social and cognitive development. This response does not require further evaluation.

A. "What were you doing when you first noticed the problem?" B. "Have you taken any medications to relieve the pain?" C. "Do you remember ever having this type of pain in the past?" D. "Does changing your position make the pain worse?

Correct Answer is A

Explanation

A. "What were you doing when you first noticed the problem?"

This question helps to identify any specific activities or events that may have triggered the onset of back pain. Understanding the circumstances surrounding the pain can provide valuable information about its potential cause.

B. "Have you taken any medications to relieve the pain?"

While it's important to assess if the adolescent has taken any medications, such as over-the-counter pain relievers, to manage the pain, this question may not be the most immediate priority. It's essential to first gather information about the nature and onset of the pain to guide further assessment and management.

C. "Do you remember ever having this type of pain in the past?"

This question helps to determine if the adolescent has a history of similar back pain episodes. Past episodes of back pain can provide insight into potential underlying conditions or recurrent issues that may be contributing to the current complaint.

D. "Does changing your position make the pain worse?"

This question is crucial in assessing the characteristics of the pain and its response to movement or positional changes. It can help differentiate between musculoskeletal causes of back pain, which may worsen with movement, and other potential causes.

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Naxlex Comprehensive Predictor Exams

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Correct Answer is A

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Correct Answer is A

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