Henry, an 80-year-old man, has had a closed head injury and was unconscious for 5 minutes. Which vital sign trend is most concerning?
Increasing respiratory rate
Rising heart rate
Decreasing blood pressure
Decreasing level of consciousness (LOC)
The Correct Answer is D
A. While an increasing respiratory rate may indicate respiratory distress, in the context of a closed head injury, decreasing level of consciousness (LOC) is a more concerning trend as it suggests worsening neurological status.
B. A rising heart rate may indicate pain, anxiety, or physiological stress, but it's not as directly related to the severity of a closed head injury.
C. While decreasing blood pressure can be concerning, especially if it indicates hypovolemic shock, in the context of a closed head injury, the primary concern is neurological status.
D. A decreasing LOC suggests worsening neurological function, which can indicate increased intracranial pressure (ICP) or neurological deterioration.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Administering the flu vaccine immediately may not be safe due to Paul's recent immunoglobulin therapy and underlying health conditions.
B. While controlling diabetes is important for overall health, it may not directly impact the decision to postpone the flu vaccine.
C. Postponing the flu vaccine for another 2 weeks allows time for the effects of immunoglobulin therapy to diminish and reduces the risk of potential adverse interactions.
D. Consulting the physician for an alternative to flu vaccination may be necessary if Paul cannot receive the vaccine due to contraindications or allergies, but postponing is the initial appropriate action.
Correct Answer is A
Explanation
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A. The nurse should focus on teaching Paul about the dangers of using a tanning booth weekly, as this is the risk factor that he can modify. A tanning booth exposes the skin to artificial ultraviolet (UV) radiation, which can damage the DNA of skin cells and increase the risk of developing malignant melanoma.
B. Dysplastic nevi (atypical moles) are also a nonmodifiable risk factor for melanoma.C. Family history of melanoma is a non-modifiable risk factor for melanoma unlike weekly use of a tanning booth which is modifiable.
D. Fair skin and blue eyes are additional risk factors for melanoma, but is non- modifiable.
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