A nurse is caring for a patient who was involved in a motor vehicle accident.The patient is alert and oriented and reports a loss of consciousness immediately after the accident.
Which of the following additional symptoms should the nurse assess the patient for? (Select All that Apply.)
Pupillary dilation
Persistent headache
Presence of hand tremors
Difficulty waking
Foot drop
Correct Answer : A,B,D
Choice A rationale
Pupillary dilation can be a sign of increased intracranial pressure, which could be a result of a traumatic brain injury following a motor vehicle accident. It’s important to assess for this symptom as it may indicate a serious condition that requires immediate medical attention.
Choice B rationale
Persistent headache is a common symptom following a head injury and can be a sign of a concussion or more serious brain injury. It’s crucial to monitor for this symptom as it can provide important information about the patient’s condition.
Choice C rationale
Presence of hand tremors is not typically associated with a head injury from a motor vehicle accident. While tremors can be a symptom of various neurological conditions, they are not commonly seen immediately after a traumatic head injury.
Choice D rationale
Difficulty waking can be a sign of a serious head injury. It could indicate a concussion or other type of traumatic brain injury. This symptom should be closely monitored as it may require immediate medical intervention.
Choice E rationale
Foot drop is not typically a symptom observed immediately after a motor vehicle accident. It’s more commonly associated with peripheral nerve conditions or stroke, rather than a head injury.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Cognitive behavioral therapy (CBT) is a type of psychological treatment that can be effective for a range of conditions, including chronic pain. However, it may not be the most suitable for acute pain management at home following a knee injury. CBT usually involves working with a trained therapist over multiple sessions, which may not be practical or immediately beneficial in this context.
Choice B rationale
Intermittent ice compress is a highly recommended non-pharmacological method for managing acute pain, especially following a knee injury. The cold temperature from the ice can help numb the area, reducing pain and inflammation. It’s a simple, cost-effective, and readily available method that can be easily applied at home.
Choice C rationale
Phototherapy, also known as light therapy, involves exposure to specific wavelengths of light using polychromatic polarised light, lasers, light-emitting diodes, fluorescent lamps, or dichroic lamps. While it has been used to treat conditions like seasonal affective disorder, skin conditions, and neonatal jaundice, its effectiveness in managing acute pain following a knee injury is not well-established.
Choice D rationale
Walking on a treadmill might not be suitable for a patient experiencing acute pain following a knee injury. Physical activity is generally beneficial for overall health and certain types of chronic pain. However, in the case of an acute knee injury, rest and immobilization are often recommended initially to allow the injured tissues to heal.
Correct Answer is B
Explanation
Choice A rationale
Serotonin is indeed an inhibitory neurotransmitter. It helps regulate mood, appetite, and sleep among other things. However, its role in the nervous system is complex and it can also have excitatory effects depending on the specific receptors and neural pathways involved.
Choice B rationale
Gamma-aminobutyric acid (GABA) is the primary inhibitory neurotransmitter in the brain. It works by decreasing neuronal excitability, which helps to regulate muscle tone, among other functions.
Choice C rationale
Acetylcholine is primarily an excitatory neurotransmitter, although it can have inhibitory effects in certain parts of the nervous system. It plays a key role in muscle activation, learning, and memory.
Choice D rationale
Dopamine can act as both an inhibitory and an excitatory neurotransmitter, depending on the type of receptor it binds to and the specific neural pathway involved. It plays key roles in reward, motivation, and motor control.
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