When performing an assessment, the nurse observes for bilateral equality. After performing a neurological assessment, which of the following will the nurse document when assessment findings indicate that there is left facial droop?

Choice A Reason: This is the correct choice. Using the rule of nines, each arm accounts for 9 percent of TBSA, each leg accounts for 18 percent of TBSA, and front and back are equally divided. Therefore, burns on both sides of both arms and legs equal to (9 + 9) x 2 + (18 + 18) x 2 = 36 percent of TBSA.

Choice B Reason: This choice is incorrect. Using the rule of nines, burns on both sides of both arms and legs equal to 36 percent of TBSA, not 54 percent. To get 54 percent of TBSA, one would have to add burns on both sides of head and neck (9 percent), chest (9 percent), and abdomen (9 percent).

Choice C Reason: This choice is incorrect. Using the rule of nines, burns on both sides of both arms and legs equal to 36 percent of TBSA, not 27 percent. To get 27 percent of TBSA, one would have to subtract burns on both sides of one leg (18 percent).

Choice D Reason: This choice is incorrect. Using the rule of nines, burns on both sides of both arms and legs equal to 36 percent of TBSA, not 18 percent. To get 18 percent of TBSA, one would have to divide burns on both sides of both arms and legs by two.

Choice E Reason: This choice is incorrect. Using the rule of nines, burns on both sides of both arms and legs equal to 36 percent of TBSA, not 9 percent. To get 9 percent of TBSA, one would have to divide burns on both sides of both arms and legs by four.

Choice A reason: This is incorrect because laceration is not an acute traumatic brain injury, but a type of wound that involves tearing or cutting of the skin or other tissues. Laceration can occur as a result of a motor vehicle accident, but it does not cause changes in the GCS or pupil size. The nurse should assess the client's skin for any signs of laceration, such as bleeding, swelling, or infection.
Choice B reason: This is incorrect because acute subdural hematoma is not likely to cause a dilated pupil on the left side. Acute subdural hematoma is a type of traumatic brain injury that involves bleeding between the dura mater and the arachnoid mater, which are two layers of the meninges that cover the brain. An acute subdural hematoma can cause a rapid decrease in the GCS, but it usually causes a dilated pupil on the same side as the injury, not on the opposite side.
Choice C reason: This is incorrect because intracerebral hemorrhage is not likely to cause a dilated pupil on the left side. Intracerebral hemorrhage is a type of traumatic brain injury that involves bleeding within the brain tissue itself. Intracerebral hemorrhage can cause a gradual decrease in the GCS, but it usually causes neurological deficits that correspond to the location of the bleeding, such as weakness, numbness, or aphasia, not pupillary changes.
Choice D reason: This is correct because epidural hematoma can cause a dilated pupil on the left side. Epidural hematoma is a type of traumatic brain injury that involves bleeding between the dura mater and the skull. Epidural hematoma can cause a lucid interval, which is a period of normal consciousness followed by a sudden decrease in the GCS, and a dilated pupil on the opposite side of the injury, due to compression of the third cranial nerve. The nurse should notify the provider immediately and prepare for emergency surgery.