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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?

A.

Diplopia

B.

Ataxia

C.

A change in the Glasgow Coma Scale score from 13 to 11

D.

A decrease in heart rate from 76 to 69 bpm

Answer and Explanation

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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View Related questions

Correct Answer is ["A","B","C","D","E"]

Explanation

A. Edema of the ear canal is a common symptom of external otitis, indicating inflammation and infection in the area.

B. Purulent drainage from the ear canal often signifies bacterial infection and is a key symptom to monitor.

C. Burning in the ear canal can occur due to inflammation and is a common complaint in external otitis.

D. Pain when moving the auricle is a classic symptom of external otitis, indicating irritation or inflammation of the external ear.

E. Tenderness of the external ear is a common finding in external otitis and should be monitored as it indicates inflammation and potential infection.

Correct Answer is B

Explanation

A. While hormones from the adrenal cortex do influence various metabolic processes, mineralocorticoids primarily focus on fluid and electrolyte balance rather than having major effects on all organs' metabolism.

B. Mineralocorticoids, such as aldosterone, play a crucial role in regulating fluid and electrolyte balance by promoting sodium retention and potassium excretion in the kidneys.

C. Regulation of carbohydrate and protein metabolism is mainly the function of glucocorticoids, not mineralocorticoids.

D. The release of ACTH is regulated by corticotropin-releasing hormone (CRH) from the hypothalamus, not directly influenced by mineralocorticoids.

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