Difficulty: Medium
Average Score: 84%
Full-length
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
Slow respirations (8) and projectile vomiting suggest increased intracranial pressure, critical in head injury, requiring immediate reporting. BP, pulse, skin, and pupil response changes are less urgent.