A nurse is caring for a client who has a head injury. The client states they fell off a ladder while painting approximately 2 hours ago and lost consciousness for 45 minutes according to their partner. The nurse should determine that the client is experiencing which of the following classifications of traumatic brain injury?

Choice A reason: Difficulty moving the upper extremities is not a complication of immobility, but a result of the stroke. A stroke can damage the part of the brain that controls movement, sensation, or coordination of the limbs, causing hemiparesis (weakness) or hemiplegia (paralysis) on one side of the body. The nurse should assist the client with passive or active range of motion exercises to prevent muscle atrophy and contractures.

Choice B reason: Stiffness in the lower extremities is not a complication of immobility, but a result of the stroke. A stroke can affect the muscle tone of the limbs, causing spasticity (increased muscle tension) or flaccidity (decreased muscle tone) on one side of the body. The nurse should apply splints or braces to prevent deformities and provide massage or stretching to relieve stiffness.

Choice C reason: A reddened area over the sacrum is a complication of immobility, and a sign of a pressure injury. A pressure injury is a localized damage to the skin and underlying tissue caused by prolonged pressure, friction, or shear. The sacrum is a common site for pressure injuries, as it is a bony prominence that bears the weight of the body when lying down. The nurse should reposition the client every 12 hours, provide skin care, and use pressure relieving devices to prevent pressure injuries.

Choice D reason: Difficulty hearing some types of sounds is not a complication of immobility, but a result of aging or other factors. Hearing loss can occur due to various causes, such as exposure to loud noise, ear infections, earwax buildup, or ototoxic medications. The nurse should assess the client's hearing and use communication strategies, such as speaking clearly, facing the client, and reducing background noise.

Choice A reason: Hypotension is not a common manifestation of ARF. Hypotension is a low blood pressure, defined as less than 90/60 mm Hg. Hypotension can have many causes, such as dehydration, blood loss, heart problems, or medications. ARF does not directly cause hypotension, but it can lead to complications such as shock or organ failure, which can lower the blood pressure.

Choice B reason: Decreased level of consciousness is a frequent manifestation of ARF. Decreased level of consciousness is a state of impaired awareness, orientation, memory, or judgment. Decreased level of consciousness can occur in ARF due to several factors, such as hypoxia, hypercapnia, acidosis, or infection. The nurse should monitor the mental status of the client with ARF and report any changes to the provider.

Choice C reason: Severe dyspnea is a common manifestation of ARF. Dyspnea is a subjective sensation of difficulty breathing or shortness of breath. Severe dyspnea can occur in ARF due to the reduced oxygen delivery or increased carbon dioxide retention in the blood. The nurse should assess the respiratory rate, rhythm, depth, and effort of the client with ARF and provide oxygen therapy as prescribed.

Choice D reason: Headache is not a typical manifestation of ARF. Headache is a pain or discomfort in the head, scalp, or neck. Headache can have many causes, such as stress, dehydration, sinusitis, or migraine. ARF does not directly cause headache, but it can cause increased intracranial pressure or cerebral edema, which can trigger headache.

Choice E reason: Nausea is not a usual manifestation of ARF. Nausea is a feeling of sickness or discomfort in the stomach that can lead to vomiting. Nausea can have many causes, such as food poisoning, motion sickness, pregnancy, or medications. ARF does not directly cause nausea, but it can cause gastrointestinal bleeding or hepatic encephalopathy, which can induce nausea.