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 C
Explanation
A. While chlorine can kill some bacteria, it does not prevent all microbial growth and does not directly explain ear infections.
B. Pool water entering the Eustachian tubes is unlikely; infections are more commonly related to pathogens in the water.
C. The best response addresses the presence of microorganisms in pool water that can enter the ear and potentially lead to infections, such as swimmer's ear (otitis externa).
D. Pool water is not typically associated with drying out the ears; rather, it can lead to excess moisture, which can promote bacterial growth.
Correct Answer is B
Explanation
A. Serum thyroxine (T4) is typically decreased in primary hypothyroidism due to reduced thyroid hormone production.
B. In primary hypothyroidism, the thyroid gland fails to produce sufficient hormones, which leads to an increase in thyroid-stimulating hormone (TSH) as the pituitary gland tries to stimulate thyroid function. Elevated TSH is a common finding in primary hypothyroidism.
C. Serum T3 is usually decreased in primary hypothyroidism since the production of T3 and T4 is reduced.
D. Free T4 is typically low in primary hypothyroidism as the thyroid gland is underactive and not producing adequate levels of thyroid hormones.