A nurse is caring for a patient in Crutchfield tongs. Which assessment finding requires immediate notification to the health-care provider?
A.
Altered mental status
B.
Crusted drainage at pin sites
C.
Irritability and pain
D.
WBCs of 98,000/mm3
ANS: A
Crutchfield tongs are inserted into the skull. Any alteration in mental status could signify a serious complication, such as infection or intracranial bleeding (both are rare but possible). The nurse would not need to report crusted drainage, irritability and pain, or a normal white blood cell count.
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