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. Quadriplegia, or tetraplegia, is typically associated with injuries at or above the C4 level, not T2-T3.
B. A T2-T3 spinal cord injury can lead to loss of sensation and motor function below the level of injury, affecting the thoracic region and lower body.
C. Hemiplegia, which refers to paralysis on one side of the body, is typically due to brain injuries or strokes, not spinal cord injuries.
D. While bladder control may be affected, the most direct impact of T2-T3 injury is the loss of sensation and motor function below that level.
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.