A nurse is caring for a client who was involved in a motor vehicle accident. The client is alert and oriented and reports a loss of consciousness immediately after the accident. Which of the following additional manifestations should the nurse assess the client for?
(Select All that Apply.)

Pupillary dilation

Persistent headache

Presence of hand tremors

Difficulty waking

Foot drop

Answer and Explanation

Correct Answer : A,B,D

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.

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Correct Answer is C

Explanation

Choice A Reason:

Respiratory alkalosis is incorrect. Tension pneumothorax typically leads to respiratory distress and hypoxemia rather than respiratory alkalosis. The respiratory alkalosis may occur initially due to hyperventilation in response to hypoxemia but would not be directly related to tracheal deviation.

Choice B Reason:

Increased venous return is incorrect. Tension pneumothorax actually leads to decreased venous return due to compression of the great vessels in the thorax, particularly the superior vena cava and the inferior vena cava. This compression results from the increased pressure within the thorax, which impedes blood flow back to the heart.

Choice C Reason:

Decreased cardiac output is incorrect. Tension pneumothorax can indeed lead to decreased cardiac output due to compression of the heart and the great vessels by the accumulating air in the pleural space. This compression decreases venous return and impairs cardiac function.

Choice D Reason:

Dilated ventricles is incorrect. As mentioned earlier, tension pneumothorax can lead to compression of the heart, including the ventricles. This compression can cause dilatation of the ventricles, particularly the right ventricle, due to increased afterload and decreased venous return.

A. Osteoporosis B. Polyuria C. Anxiety and depression D. Delirium

Correct Answer is D

Explanation

Choice A Reason:

Osteoporosis is inappropriate. Chronic respiratory acidosis can lead to osteoporosis over time due to several factors, including chronic hypoxemia, which can affect bone metabolism and lead to bone loss.

Choice B Reason:

Polyuria is inappropriate. Polyuria, or increased urination, is not typically associated with chronic respiratory acidosis. In fact, respiratory acidosis tends to cause retention of bicarbonate ions, which can lead to compensatory metabolic alkalosis and decreased urine output.

Choice C Reason:

Anxiety and depression is inappropriate. Chronic respiratory acidosis can lead to symptoms such as lethargy, confusion, and decreased mental acuity due to the effects of elevated CO2 levels on the central nervous system. While anxiety and depression are not direct consequences of chronic respiratory acidosis, individuals with COPD may experience anxiety and depression as a result of their chronic respiratory condition.

Choice D Reason:

Delirium is correct. Delirium, characterized by an acute change in mental status, confusion, and altered consciousness, can occur in severe cases of chronic respiratory acidosis, especially during acute exacerbations. Elevated CO2 levels can affect brain function and lead to symptoms of delirium.

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A nurse is caring for a client who was involved in a motor vehicle accident. The client is alert and oriented and reports a loss of consciousness immediately after the accident. Which of the following additional manifestations should the nurse assess the client for? (Select All that Apply.)

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Correct Answer is C

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Correct Answer is D

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A nurse is caring for a client who was involved in a motor vehicle accident. The client is alert and oriented and reports a loss of consciousness immediately after the accident. Which of the following additional manifestations should the nurse assess the client for?
(Select All that Apply.)