Traumatic Brain Injury: Concussions,

Traumatic Brain Injury: Concussions, ( 8 Questions)

A nurse is performing a neurological assessment on a client who has a concussion. Which of the following findings should the nurse report to the provider immediately?


Correct Answer: B

Choice A reason:

This is an incorrect answer. The client does not need immediate reporting if they have a GCS score of 15. This is the highest possible score on the GCS, which indicates that the client is fully alert and oriented.

Choice B reason:

This is a correct answer. The client needs immediate reporting if they have unequal pupils with a difference of 2 mm. This is an abnormal finding that indicates increased intracranial pressure (ICP) or cranial nerve damage, which can be life-threatening.

Choice C reason:

This is an incorrect answer. The client does not need immediate reporting if they have a positive Babinski reflex on both feet. This is a normal finding in infants and young children, but an abnormal finding in adults. However, it does not indicate an acute or urgent condition, but rather a chronic or long-term damage to the corticospinal tract.

Choice D reason:

This is an incorrect answer. The client does not need immediate reporting if they have difficulty performing finger-to-nose test. This is an abnormal finding that indicates cerebellar dysfunction, which affects coordination and balance. However, it does not indicate an acute or urgent condition, but rather a mild or moderate impairment.




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