Difficulty: Medium
Average Score: 69%
Full-length
A 19-year-old client fell off a ladder approximately 3 ft to the ground. He did not lose consciousness but was taken to the emergency department by a friend to have a scalp laceration sutured. The nurse instructs the client to:
Correct answer
C
Rationale
Confusion, nausea, or vomiting may indicate increasing intracranial pressure from a possible head injury, requiring immediate evaluation.