A nurse is caring for a client who has a mild traumatic brain injury (TBI). Which of the following manifestations should the nurse immediately report to the provider?
Diplopia
Ataxia
A change in the Glasgow Coma Scale score from 13 to 11
A decrease in heart rate from 76 to 69 bpm
The Correct Answer is C
A. Diplopia is a concerning symptom but does not indicate immediate deterioration in neurological status like a change in GCS does.
B. Ataxia is also significant but is less acute than a drop in GCS score.
C. A change in the Glasgow Coma Scale score from 13 to 11 indicates a worsening level of consciousness and necessitates immediate reporting, as it may suggest increased intracranial pressure or other complications.
D. A decrease in heart rate from 76 to 69 bpm is not significant enough in the context of TBI to warrant immediate reporting, as it remains within a normal range.
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Correct Answer is A
Explanation
A. Miotic medications work by constricting the pupil, which opens the trabecular meshwork and facilitates the drainage of aqueous humor, thus lowering intraocular pressure in clients with glaucoma.
B. Miotics do not dilate the pupil; they constrict it. Dilation would actually increase intraocular pressure, which is not therapeutic in glaucoma.
C. While these medications do affect eye muscles, they do not specifically prevent blurred vision; their primary effect is on eye pressure.
D. Miotics do not block nerve responses; they work by direct action on the eye muscles to promote fluid drainage and reduce pressure.
Correct Answer is A
Explanation
A. In SIADH, excess ADH causes water retention and hyponatremia; fluid restriction helps to prevent further dilution of sodium and manage fluid balance.
B. NPO status is unnecessary unless otherwise indicated; managing fluid intake is more effective.
C. Increasing oral intake would worsen fluid overload and hyponatremia.
D. Rapid IV fluid infusion can exacerbate the client’s condition by increasing fluid volume further.