Exhibits

What laboratory specimens would the nurse expect for the provider to order? Select all that apply.

Blood culture

Prothrombin time

Hemoglobin and hematocrit

Type and screen

Albumin

Lipid panel

Answer and Explanation

Correct Answer : A,B,C,D

A. Blood culture is essential to identify any potential infection that the patient may have, which is a common complication after trauma.
B . Prothrombin time is crucial for assessing the blood's clotting ability, especially since the patient has a suspected fracture and could be at risk of bleeding.
C . Hemoglobin and hematocrit are fundamental tests to evaluate for anemia or blood loss, which is particularly relevant given the patient's fall and the possibility of internal injuries. D . Type and screen is necessary in case the patient requires a blood transfusion due to the injuries sustained from the fall.
E . Albumin is not typically a priority in acute trauma settings and would not necessarily be expected as an immediate test.
F . Lipid panel is not relevant in the acute management of trauma and is not typically ordered in the emergency setting

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Correct Answer is B

Explanation

A. Instruct the family about withdrawal symptoms. While educating the family about withdrawal symptoms is important for support and understanding, it is not the best initial action when the
client is experiencing severe agitation and tremors. Safety measures should be prioritized.

B. Initiate seizure precautions. Severe agitation and tremors can be signs of benzodiazepine withdrawal, which may progress to seizures. Initiating seizure precautions, such as ensuring a
safe environment, padding side rails, and having emergency medications and equipment readily available, is the priority to prevent injury.
C. Obtain a serum drug screen. While obtaining a serum drug screen may be necessary to confirm benzodiazepine withdrawal, it is not the immediate action needed to address the client's current symptoms and prevent potential harm.
D. Administer naloxone per PRN protocol. Naloxone is an opioid antagonist used to reverse opioid overdose and is not indicated for benzodiazepine withdrawal. Administering naloxone would not be appropriate or effective in this situation.

A. The client may be developing sepsis. B. The client may be dehydrated. C. The client may have increasing symptoms of head injury. D. The client may have been sleeping. E. The client may be improving clinically. F. The client may require more morphine G. The client may be experiencing sedative effects of morphine.

Correct Answer is ["C","D","G"]

Explanation

A. The client may be developing sepsis.

Sepsis typically presents with symptoms such as fever, increased heart rate, increased respiratory rate, and altered blood pressure. There is no indication of these signs in the provided data,
making sepsis an unlikely cause for the change in the Glasgow Coma Scale (GCS) score.

B. The client may be dehydrated.

Dehydration can affect cognitive function, but there is no evidence suggesting dehydration in this scenario (e.g., normal heart rate, blood pressure, and no noted intake/output imbalance).
C. The client may have increasing symptoms of head injury.

A decrease in GCS score can indicate worsening head injury symptoms, such as increased intracranial pressure or bleeding.
D. The client may have been sleeping.

Sleeping can temporarily affect the GCS score, particularly the eye-opening component.

E. The client may be improving clinically.

Improvement clinically would likely result in a stable or improved GCS score, not a decrease.

F. The client may require more morphine.

Needing more morphine would typically be due to increased pain, but this should not directly affect the GCS score unless severe pain is causing altered consciousness, which is not indicated here.
G. The client may be experiencing sedative effects of morphine.

Morphine, especially given intravenously, can cause sedation, which could lower the GCS score.

H. The client may need food.

Needing food would not typically cause an immediate change in GCS score unless associated with severe hypoglycemia, which is not indicated by the provided data.

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Exhibits What laboratory specimens would the nurse expect for the provider to order? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client experiencing withdrawal from the benzodiazepine alprazolam is demonstrating severe agitation and tremors. Which is the best initial nursing action?

Correct Answer is B

Explanation

Exhibits Which may have caused the change in the Glasgow Coma Scale score between 2000 and 2400? Select all that apply.

Correct Answer is ["C","D","G"]

Explanation

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Exhibits

What laboratory specimens would the nurse expect for the provider to order? Select all that apply.