A nurse is teaching a client about the use of ice for treatment of a soft-tissue injury. Which of the following instructions should be included? (Select All that Apply.)

Choice A Reason: Pupillary dilation

Pupillary dilation can be a sign of increased intracranial pressure or brain injury, which are potential complications following a motor vehicle accident with a loss of consciousness. Assessing for changes in pupil size and reactivity is crucial in identifying neurological impairments that may require immediate intervention.

Choice B Reason: Persistent headache

A persistent headache is a common symptom following a traumatic brain injury (TBI) or concussion. It can indicate ongoing issues such as intracranial bleeding or increased intracranial pressure. Monitoring the severity and duration of the headache is important for determining the need for further medical evaluation and treatment.

Choice C Reason: Presence of hand tremors

Hand tremors are not typically associated with acute brain injuries resulting from a motor vehicle accident. They are more commonly linked to conditions such as Parkinson’s disease, essential tremor, or other neurological disorders. While tremors should be noted, they are not a primary concern in the context of post-accident assessment.

Choice D Reason: Difficulty waking

Difficulty waking, or altered level of consciousness, is a significant indicator of potential brain injury or increased intracranial pressure. It is essential to monitor the client’s level of consciousness closely, as changes can signal worsening neurological status and the need for urgent medical intervention.

Choice E Reason: Foot drop

Foot drop is a condition characterized by difficulty lifting the front part of the foot, often due to nerve damage or muscle weakness. While it can occur in the context of neurological injury, it is not a primary manifestation to assess for immediately following a motor vehicle accident with a loss of consciousness. The focus should be on more acute signs of brain injury.

Choice A Reason: The most important thing is that now you are here, and it is going to get taken care of

While this statement is reassuring, it does not provide the client with the specific information they are seeking about adhesions. Clients often feel more at ease when they understand the cause of their condition. Providing clear and accurate information helps reduce anxiety and empowers the client to be more involved in their care.

Choice B Reason: This means that scar tissue formed from the healing of a past abdominal surgery is now constricting the opening in your intestine

This statement is the best response because it directly addresses the client’s question about adhesions. Adhesions are bands of scar tissue that can form after abdominal surgery, causing organs or tissues to stick together. These adhesions can constrict the intestines, leading to a blockage. Providing this explanation helps the client understand the cause of their condition and the reason for the surgery.

Choice C Reason: I will be happy to go and get you some reading materials about this procedure to explain it further

Offering reading materials can be helpful, but it does not immediately address the client’s anxiety or their specific question about adhesions. While additional information can be beneficial, the nurse should first provide a clear and direct explanation to help the client understand their condition.

Choice D Reason: It’s okay. It happens all the time and I’ve seen a lot of clients with this issue

This statement may come across as dismissive and does not provide the client with the information they need. While it is important to reassure the client, it is equally important to provide specific information about their condition. Understanding the cause of their symptoms can help reduce anxiety and improve the client’s overall experience.