NCLEX RN > EXAM > Real U-World NCLEX NGN Prioritization paper, Questions and Answers with Rational Test Bank,2023 (All)
Real U-World NCLEX NGN Prioritization paper, Questions and Answers with Rational Test Bank,2023
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The nurse is managing assigned clients on the evening shift. Which client presentation is a priority? Unordered Options Ordered Response 1. Blunt head trauma with projectile vomiting 2. Hist... ory of Alzheimer disease with agitation 3. History of carpal tunnel syndrome with hand numbness 4. History of third cranial nerve pathology with double vision Explanation A client with a traumatic head injury from blunt force can have delayed symptoms if there is bruising in the brain and subdural hematoma/cerebral edema develops. A subdural hematoma is typically a slower venous bleed, and symptoms appear 24-48 hours later. Signs and symptoms are similar to those of increased intracranial pressure and include change in level of consciousness, projectile vomiting, ataxia, ipsilateral (unilateral) pupil dilation, and seizures. Brain herniation can occur if the condition is not recognized and treated. (Option 2) Neuropsychiatric symptoms such as agitation, aggression, delusions, hallucinations, wandering, and depression are very common in clients with dementia. Some may have an underlying etiology (eg, pain, infection) that requires identification and treatment. This client is the second priority as the condition is not immediately life- threatening. (Option 3) Carpal tunnel syndrome is a compression of the median nerve within the carpal tunnel at the wrist. Clinical manifestations are weakness, pain, numbness, and impaired sensation in the median nerve distribution. Numbness is an expected symptom; a splint is worn to relieve the pressure. (Option 4) The third cranial nerve controls the majority (4/6) of the extraocular muscles. As a result, the lesion can cause weakness in eye movements with resultant diplopia, which is an expected finding. Educational objective: A client with a head injury and signs of increased intracranial pressure (eg, change in level of consciousness, projectile vomiting, pupil dilation, ataxia) is a priority. [Show More]
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