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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A Reason:
Bronchopneumonia is incorrect. Bronchopneumonia is characterized by patchy areas of consolidation involving multiple lobules scattered throughout the lungs. It typically results from bronchial obstruction and aspiration of infected material into the smaller airways and alveoli.
Choice B Reason:
Severe pneumonia is incorrect. "Severe pneumonia" is a broad term that can refer to pneumonia with various degrees of severity. It does not specifically describe the pattern of consolidation involving the entire lobe of the lung.
Choice C Reason:
Empyema is incorrect. Empyema refers to the accumulation of pus in the pleural cavity, often as a complication of pneumonia. It does not describe the pattern of consolidation within the lung tissue.
Choice D Reason:
Lobar pneumonia is correct. Lobar pneumonia is characterized by consolidation involving an entire lobe or lobes of the lung. It typically results from infection by a single pathogen, such as Streptococcus pneumoniae, which leads to inflammation and consolidation of an entire lobe of the lung.
Correct Answer is A
Explanation
Choice A Reason:
COPD is a chronic lung condition characterized by airflow limitation that is not fully reversible. Individuals with COPD often have underlying structural lung changes, such as emphysematous bullae or blebs. These areas of weakened lung tissue are prone to rupture, leading to the development of pneumothorax. Additionally, the chronic inflammation and damage to the airways and lung parenchyma in COPD contribute to the development of pneumothorax.
Choice B Reason:
Sarcoidosis is incorrect. Sarcoidosis is a granulomatous disease that primarily affects the lungs and lymph nodes. While it can cause lung damage and lead to pneumothorax, it is less common than COPD as a comorbidity associated with SSP.
Choice C Reason:
Lung cancer is incorrect. Lung cancer can lead to pneumothorax, especially if the tumor erodes into the pleural space. However, SSP is more commonly associated with underlying lung diseases like COPD rather than lung cancer.
Choice D Reason:
Cystic fibrosis is incorrect. Cystic fibrosis is a genetic disorder characterized by abnormal mucus production and impaired clearance in various organs, including the lungs. While individuals with cystic fibrosis are at increased risk of pneumothorax due to underlying lung disease, SSP is less commonly seen in this population compared to COPD.
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