A nurse is caring for a client who has spinal stenosis. Which of the following conditions should the nurse recognize as a risk factor for spinal stenosis?

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:

Air cannot pass freely into the thoracic cavity through a chest wound is incorrect because air can indeed pass freely into the thoracic cavity through the chest wound in an open pneumothorax.

Choice B Reason:

The air is trapped when it enters the cavity is incorrect because the characteristic feature of an open pneumothorax is that air is not trapped; rather, it enters the thoracic cavity with each inhalation and exits with each exhalation through the chest wound.

Choice C Reason:

Air moves in and out of a wound in the chest wall is correct. In an open pneumothorax, also known as a "sucking chest wound," air can freely move in and out of the thoracic cavity through a wound in the chest wall. This occurs due to the creation of a communication pathway between the external environment and the pleural space, typically caused by a penetrating injury to the chest.

Choice D Reason:

There are no audible sounds in an open pneumothorax is incorrect because in an open pneumothorax, there may be audible sounds associated with the movement of air in and out of the wound, such as a sucking or bubbling sound, depending on the size and location of the wound. These sounds can be clinically significant and aid in the diagnosis of an open pneumothorax.