A nurse is assisting with the plan of care for a client who has a spinal cord injury and spasm-induced incontinence. Which of the following medications should the nurse anticipate a prescription for?

Choice A Reason:

Pupillary dilation is correct. Pupillary changes can indicate neurological dysfunction following a head injury. Dilated pupils may suggest increased intracranial pressure or damage to specific brain structures.

Choice B Reason:

Persistent headache is correct .Headaches are a common symptom following a head injury. Persistent or worsening headaches can indicate ongoing neurological issues and should be monitored closely.

Choice C Reason:

Presence of hand tremors is incorrect. Hand tremors are not typically associated with loss of consciousness following a motor vehicle accident. While hand tremors can occur in various conditions, such as essential tremor or Parkinson's disease, they are not typically a direct manifestation of a head injury. The primary concern immediately following a motor vehicle accident with loss of consciousness is assessing for signs of neurological dysfunction, such as altered level of consciousness, pupillary changes, and persistent headache. Hand tremors may be assessed in other contexts, but they are not directly related to the immediate assessment of a client following a motor vehicle accident with loss of consciousness.

Choice D Reason:

Difficulty waking is correct. Difficulty waking or altered level of consciousness can indicate neurological impairment and may be indicative of a concussion or other brain injury.

E. Foot drop is incorrect. Foot drop refers to difficulty lifting the front part of the foot, which can cause dragging of the foot or toes along the ground while walking. While foot drop can result from various neurological conditions or injuries, it is not typically associated with loss of consciousness following a motor vehicle accident. Loss of consciousness after a motor vehicle accident is more indicative of potential head trauma or concussion, which may present with symptoms such as altered level of consciousness, headache, pupillary changes, or difficulty waking. Foot drop would be more relevant to assess in contexts related to peripheral nerve injury, spinal cord injury, or neurological conditions affecting the lower extremities. Given the scenario provided, foot drop is not a typical manifestation that the nurse would assess for immediately following a motor vehicle accident with loss of consciousness. Therefore, option E is not relevant in this scenario.

Choice A Reason:

Paralytic ileus is incorrect. Paralytic ileus is a condition characterized by obstruction of the intestines due to paralysis of the intestinal muscles, resulting in symptoms such as abdominal pain, bloating, and constipation. Paralytic ileus is not typically associated with cauda equina syndrome, which primarily affects the nerves in the lower back and lower extremities.

Choice B Reason:

Blood pressure 80/48 mm Hg is incorrect. While cauda equina syndrome can cause neurological symptoms such as lower extremity weakness, numbness, and bowel or bladder dysfunction, it is not typically associated with alterations in blood pressure. Blood pressure changes may occur in response to pain or other systemic factors, but they are not specific to cauda equina syndrome.

Choice C Reason:

Weakness in one or both legs is correct. Yes, weakness in one or both legs is a characteristic finding of cauda equina syndrome. Compression of the nerve roots in the lower spinal cord can lead to motor deficits, including weakness, difficulty walking, and loss of reflexes in the lower extremities.

Choice D Reason:

Potassium 3.2 mEq/L is incorrect. Serum potassium levels are not typically associated with cauda equina syndrome. Abnormal potassium levels may be indicative of electrolyte imbalances, which can occur in various medical conditions but are not specific to cauda equina syndrome.