The nurse is completing a neurological assessment on a client with a head injury. The Glasgow Coma Scale (GCS) score is 14. Which intervention should the nurse implement?

Prepare to give phenytoin IV as prescribed.

Perform a substernal rub to evoke a response to pain.

Promptly notify the healthcare provider (HCP) of the GCS score.

Continue monitoring the client's GCS score every 2 hours.

Answer and Explanation

The Correct Answer is D

A. Prepare to give phenytoin IV as prescribed. Phenytoin is used for seizure prophylaxis in clients with moderate to severe head injuries (GCS ≤ 8–10). A GCS score of 14 indicates mild head injury, and prophylactic anticonvulsants may not be necessary unless ordered for specific risk factors.
B. Perform a substernal rub to evoke a response to pain. A substernal rub (painful stimulus) is used to assess response in unconscious or unresponsive clients (GCS ≤ 8). With a GCS of 14, the client is alert or nearly fully conscious, making a painful stimulus unnecessary and inappropriate.
C. Promptly notify the healthcare provider (HCP) of the GCS score. A GCS of 14 is not a critical or emergency finding, as it indicates mild neurological impairment. While the HCP should be updated on significant changes, routine monitoring is sufficient unless deterioration occurs.
D. Continue monitoring the client's GCS score every 2 hours. Frequent neurological assessments are crucial in head injury management to detect worsening conditions like increasing intracranial pressure (ICP) or cerebral edema. Monitoring the GCS every 2 hours ensures timely intervention if the client’s condition changes.

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

Explanation

A. Low PaO2. Clients with DKA do not typically have significant hypoxemia unless there is concurrent respiratory compromise. The primary issue in DKA is metabolic acidosis rather than oxygenation.
B. Low lactic acid. Lactic acidosis is not a hallmark of DKA. Instead, DKA is characterized by ketone production from fatty acid metabolism. Elevated lactic acid is more common in conditions like sepsis or tissue hypoxia.
C. Low pH. Diabetic ketoacidosis (DKA) causes metabolic acidosis due to the accumulation of ketone bodies, leading to a pH below 7.35. The absence of insulin results in unregulated lipolysis and ketogenesis, significantly lowering blood pH.
D. Low bicarbonate (HCO3-). In metabolic acidosis, bicarbonate acts as a buffer and gets depleted while neutralizing excess acids. Clients with DKA typically have a bicarbonate level below 18 mEq/L (18 mmol/L), confirming metabolic acidosis.
E. High PaCO2. In metabolic acidosis, respiratory compensation leads to hyperventilation (Kussmaul respirations), causing PaCO2 to decrease as the body attempts to blow off excess CO2 to normalize pH.

Correct Answer is []

Explanation

Answer:

Potential Condition:

Acute Adrenal Crisis

The client has a history of Addison’s disease (chronic steroid use) and recent illness with vomiting, leading to decreased oral intake and medication noncompliance.
Symptoms such as hypotension (80/50 mmHg), tachycardia (115 bpm), confusion, nausea, vomiting, and abdominal pain are classic signs of acute adrenal insufficiency.

Actions to Take:

Bolus Intravenous Fluids

Fluid resuscitation with 0.9% normal saline is critical to restore intravascular volume and correct hypotension due to adrenal insufficiency.

Check Blood Glucose

Hypoglycemia is a common complication of adrenal crisis due to cortisol deficiency, requiring close monitoring and possible glucose administration.

Parameters to Monitor:

Blood Pressure

Hypotension is a hallmark of adrenal crisis and must be monitored closely to assess response to fluid resuscitation and steroid therapy.

Electrolytes

Clients with adrenal crisis often have hyponatremia and hyperkalemia due to aldosterone deficiency, requiring frequent electrolyte monitoring.

Incorrect Choices:

Potential Conditions:

Ketoacidosis: More common in diabetes, presents with high blood glucose and ketonuria.
Diabetes Insipidus: Causes polyuria and dehydration but lacks hypotension and hyperkalemia.
Myxedema: Linked to hypothyroidism, causing bradycardia and hypothermia, not hypotension and hyperkalemia.

Actions to Take:

Hold hydrocortisone dose: Steroid replacement is necessary, not withholding it.
Collect urine for a urinalysis: Not a priority; adrenal crisis is diagnosed via history, symptoms, and labs.
Change intravenous fluids to 0.45%: Hypotension requires 0.9% normal saline, not hypotonic fluids.

Parameters to Monitor:

Urine output: Useful but less critical than blood pressure and electrolytes in adrenal crisis.
Thyroid stimulating hormone: Relevant for hypothyroidism, not adrenal insufficiency.
Heart rate: Tachycardia is expected but is not the most critical indicator of improvement.

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The nurse is completing a neurological assessment on a client with a head injury. The Glasgow Coma Scale (GCS) score is 14. Which intervention should the nurse implement?

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Naxlex Comprehensive Predictor Exams

Exhibits Based on the client's diagnosis, which results does the nurse expect in the blood gas? Select all that apply

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

Explanation

Correct Answer is []

Explanation

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