weaknesses

Question 1

1. 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?

Answer 1

A. A change in the Glasgow Coma Scale score from 13 to 11
Rationale: In a client who has mild TBI, a decrease of 2 points on the Glasgow Coma Scale indicates a
decrease in level of consciousness and that the client is risk of a deteriorating neurologic status.
Therefore, this finding is the priority to report to the provider.
B. Diplopia
Rationale: In a client who has mild TBI, diplopia indicates a risk for damage to the optic tract and should be
reported to the provider; however, another finding is the priority to report.
C. A drop in heart rate from 76 to 70/min
Rationale: In a client who has mild TBI, a decrease in heart rate indicates that the client is at risk for
increasing intracranial pressure, but this client’s heart rate has not dropped below 60/min.
Therefore, another finding is the priority to report.
D. Ataxia
Rationale: In a client who has mild TBI, ataxia indicates a risk for brainstem or cerebellar injury and should
be reported to the provider; however, another finding is the priority.