A nurse is caring for a client who was involved in a motor vehicle accident. The client is alert and oriented and reports a loss of consciousness immediately after the accident. Which of the following additional manifestations should the nurse assess the client for?
(Select All that Apply.)

Pupillary dilation

Persistent headache

Presence of hand tremors

Difficulty waking

Foot drop

Answer and Explanation

Correct Answer : A,B,D

Choice A Reason:

Pupillary dilation is correct. Pupillary changes can indicate neurological dysfunction following a head injury. Dilated pupils may suggest increased intracranial pressure or damage to specific brain structures.

Choice B Reason:

Persistent headache is correct .Headaches are a common symptom following a head injury. Persistent or worsening headaches can indicate ongoing neurological issues and should be monitored closely.

Choice C Reason:

Presence of hand tremors is incorrect. Hand tremors are not typically associated with loss of consciousness following a motor vehicle accident. While hand tremors can occur in various conditions, such as essential tremor or Parkinson's disease, they are not typically a direct manifestation of a head injury. The primary concern immediately following a motor vehicle accident with loss of consciousness is assessing for signs of neurological dysfunction, such as altered level of consciousness, pupillary changes, and persistent headache. Hand tremors may be assessed in other contexts, but they are not directly related to the immediate assessment of a client following a motor vehicle accident with loss of consciousness.

Choice D Reason:

Difficulty waking is correct. Difficulty waking or altered level of consciousness can indicate neurological impairment and may be indicative of a concussion or other brain injury.

E. Foot drop is incorrect. Foot drop refers to difficulty lifting the front part of the foot, which can cause dragging of the foot or toes along the ground while walking. While foot drop can result from various neurological conditions or injuries, it is not typically associated with loss of consciousness following a motor vehicle accident. Loss of consciousness after a motor vehicle accident is more indicative of potential head trauma or concussion, which may present with symptoms such as altered level of consciousness, headache, pupillary changes, or difficulty waking. Foot drop would be more relevant to assess in contexts related to peripheral nerve injury, spinal cord injury, or neurological conditions affecting the lower extremities. Given the scenario provided, foot drop is not a typical manifestation that the nurse would assess for immediately following a motor vehicle accident with loss of consciousness. Therefore, option E is not relevant in this scenario.

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Correct Answer is A

Explanation

Choice A Reason:

Hypertension is correct. This is a modifiable risk factor for stroke. Hypertension, or high blood pressure, significantly increases the risk of stroke. Treating and controlling hypertension through lifestyle changes and medication can help reduce the risk of stroke.

Choice B Reason:

Client's age is incorrect. While age itself is not modifiable, age is a non-modifiable risk factor for stroke. Risk of stroke increases with age, particularly in individuals over 55 years old. However, other modifiable risk factors can be addressed to reduce overall risk.

Choice C Reason:

History of sickle cell disease is incorrect. Sickle cell disease is a genetic disorder characterized by abnormal hemoglobin in red blood cells. While sickle cell disease increases the risk of certain complications, such as stroke in children, it is not a modifiable risk factor in the traditional sense.

Choice D Reason:

Parent who has cardiovascular disease is incorrect. While having a parent with cardiovascular disease may indicate a genetic predisposition to certain risk factors, it is not a direct modifiable risk factor for stroke. However, individuals with a family history of cardiovascular disease may have increased awareness and motivation to address modifiable risk factors such as hypertension, smoking, and diabetes.

A. Repeating the same question over and over B. Awareness of COPD manifestations C. Anxiety and restlessness D. Motivation and engagement of the client

Correct Answer is D

Explanation

Choice A Reason:

Repeating the same question over and over is incorrect. Repeating the same question over and over is not a desired outcome of client education. It may indicate confusion or cognitive impairment rather than effective learning and understanding of COPD management.

Choice B Reason:

Awareness of COPD manifestations is incorrect. This is a desirable outcome of client education. Increasing the client's awareness of COPD manifestations, such as dyspnea, coughing, and sputum production, can help them recognize exacerbations early and take appropriate action to manage their condition.

Choice C Reason:

Anxiety and restlessness is incorrect. Anxiety and restlessness are not desired outcomes of client education. While anxiety is common in individuals with COPD due to the chronic nature of the condition and its impact on daily activities, education should aim to reduce anxiety by providing information and strategies for coping with COPD-related symptoms and challenges.

Choice D Reason:

Motivation and engagement of the client is correct. This is a desirable outcome of client education. Motivating and engaging the client in their own care empowers them to take an active role in managing their COPD and improving their quality of life. Education should provide information, support, and encouragement to help the client feel motivated and engaged in self-management strategies.

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A nurse is caring for a client who was involved in a motor vehicle accident. The client is alert and oriented and reports a loss of consciousness immediately after the accident. Which of the following additional manifestations should the nurse assess the client for? (Select All that Apply.)

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A nurse is caring for a client who was involved in a motor vehicle accident. The client is alert and oriented and reports a loss of consciousness immediately after the accident. Which of the following additional manifestations should the nurse assess the client for?
(Select All that Apply.)