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 A
Explanation
Choice A rationale
The aura phase is characterized by sensory, motor, or visual disturbances that occur before the headache phase of a migraine. Symptoms such as tingling of the face and blind spots in the eyes are common during this phase.
Choice B rationale
The postdrome phase, also known as the “migraine hangover,” occurs after the headache phase. It does not typically include symptoms such as tingling of the face or blind spots in the eyes.
Choice C rationale
The prodrome phase, also known as the pre-headache phase, can occur hours to days before the headache phase. It can include symptoms such as mood changes, food cravings, and neck stiffness, but not typically tingling of the face or blind spots in the eyes.
Choice D rationale
The headache phase is the period during a migraine when the actual headache occurs. It is not typically associated with symptoms such as tingling of the face or blind spots in the eyes.
Correct Answer is A
Explanation
Choice A rationale
A Computerized Tomography Angiography (CTA) scan is often used to diagnose a Transient Ischemic Attack (TIA). This imaging test can provide detailed images of blood vessels in the brain and neck, allowing healthcare providers to identify blockages or other abnormalities that could have caused the TIA12.
Choice B rationale
A Transesophageal Echocardiogram (TEE) is a type of echocardiogram that uses a probe passed down the esophagus to obtain detailed images of the heart. While it can be useful in diagnosing certain heart conditions, it is not typically the first-line diagnostic test for a TIA12.
Choice C rationale
A Complete Blood Count (CBC) is a blood test that measures different components of the blood, including red and white blood cells and platelets. While it can provide useful information about a person’s overall health, it is not typically used to diagnose a TIA12.
Choice D rationale
Prothrombin Time (PT) is a blood test that measures how long it takes for your blood to clot. While it can provide information about clotting disorders, it is not typically used to diagnose a
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