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 B
Explanation
A. Profound hypocalcemia is not associated with hyperthyroidism; it is more common in hypoparathyroidism.
B. Thyroid Storm is a life-threatening complication of hyperthyroidism, characterized by high fever, tachycardia, hypertension, and altered mental status. It requires immediate medical intervention to prevent serious outcomes.
C. Diabetes Insipidus is unrelated to hyperthyroidism and typically occurs due to antidiuretic hormone dysfunction.
D. Severe hypotension is not a typical complication of hyperthyroidism; rather, hypertension is more likely due to increased metabolic rate and cardiac output.
Correct Answer is B
Explanation
A. The Glasgow Coma Scale is useful for assessing consciousness levels but may not be as sensitive for changes in brainstem function in a patient already in an induced coma.
B. Assessing pupillary size and reaction provides critical information on brainstem function and can indicate changes in ICP. Changes in pupil size and reaction can signify worsening cerebral function or brain herniation.
C. Blood pressure and heart rate are vital signs that can suggest increased ICP, but they are not as direct an indicator of cerebral function as pupil assessment.
D. The gag reflex is important but does not provide as direct information about cerebral function related to ICP as pupillary assessment does.