A nurse is caring for a client who has a new diagnosis of liver disease. Which of the following manifestations should the nurse expect?

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:

This option suggests removing the mask before removing gloves. However, the correct procedure is to remove gloves first, followed by the mask, to prevent contamination from the gloves to the face.

Choice B Reason:

This is the correct answer. Medical masks should be discarded after each use to prevent contamination and ensure effectiveness. Reusing masks can lead to the spread of pathogens.

Choice C Reason:

While positioning the mask correctly is important, the statement contains an error. The flexible metal piece should be at the top of the mask, not the bottom.

Choice D Reason:

Touching the front of the mask while wearing it is incorrect as it can lead to contamination. The front of the mask is considered contaminated, and touching it can transfer pathogens to the hands.