NCLEX PN Practice Test Practice Question
A young adult is admitted with a possible head injury. The car in which he was riding hit a utility pole, and the client's head hit the windshield. Baseline vital signs are BP=112/74, P=80, and R=12. The nurse checks the client an hour after admission. Which finding(s) are significant and should be reported to the charge nurse or physician immediately? Select all that apply.
Correct Answer: C,D
Rationale: Respiratory rate of 8 (C) indicates significant respiratory depression, which can lead to inadequate oxygenation and requires immediate intervention. Projectile vomiting (D) is a concerning sign of increased intracranial pressure or potential brain injury, necessitating urgent medical attention.
The other options do not indicate immediate danger: BP of 126/68 (A) is within acceptable limits, showing no significant change. A pulse of 62 (B) is slightly bradycardic but not alarming in the context. Cool skin (E) may suggest peripheral circulation issues but is not an acute emergency. Pupillary response (F) is normal, indicating no immediate neurological compromise.
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