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 D
Explanation
A. Increased insulin production would not cause polyuria and low specific gravity urine; rather, hyperglycemia from lack of insulin can cause high specific gravity due to glucose in urine.
B. Increased ACTH affects cortisol production but is not directly related to urine concentration or polyuria.
C. Low T3 and T4 levels are associated with hypothyroidism, which typically does not cause polyuria or decreased specific gravity.
D. Insufficient ADH, as seen in diabetes insipidus, leads to the inability to concentrate urine, resulting in a low specific gravity, polyuria, and nocturia due to excessive water loss.
Correct Answer is ["A","C","D"]
Explanation
A. Calcium binders are used to help decrease the amount of calcium absorbed from the gastrointestinal tract, thus lowering calcium levels in the blood.
B. Vitamin D supplements would actually increase calcium levels by enhancing intestinal absorption, so this option is not appropriate in hypercalcemia.
C. Administering fluids helps to dilute serum calcium levels and promote renal excretion of calcium, making it a priority treatment.
D. Furosemide (Lasix) can help promote diuresis, thereby increasing the excretion of calcium through the urine, which is beneficial in managing hypercalcemia.
E. Oral phosphates may be used in some cases to manage hypercalcemia, but they are not a first-line treatment and their administration should be carefully considered in conjunction with other treatments.