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 D

Explanation

Choice A Reason:

Myelogram is not appropriate. This imaging test involves injecting contrast dye into the spinal canal to visualize the spinal cord and nerve roots. While it may help identify certain spinal cord abnormalities, it is not typically used as a primary diagnostic tool for multiple sclerosis.

Choice B Reason:

Brain natriuretic peptide (BNP) is not appropriate. This blood test measures the level of BNP, a hormone produced by the heart, which can be elevated in conditions such as heart failure. It is not used in the diagnosis of multiple sclerosis.

Choice C Reason:

Troponin level is not appropriate. Troponin is a protein released into the bloodstream during a heart attack or other heart-related conditions. This test is used to diagnose heart muscle damage and is not relevant to the diagnosis of multiple sclerosis.

Choice D Reason:

Lumbar puncture is appropriate. Also known as a spinal tap, a lumbar puncture involves collecting cerebrospinal fluid (CSF) from the spinal canal for analysis. In the diagnosis of multiple sclerosis, analysis of CSF can help identify certain abnormalities, such as an elevated level of immunoglobulin G (IgG) or the presence of oligoclonal bands, which are often indicative of inflammation in the central nervous system. Therefore, a lumbar puncture is commonly ordered to assist with the diagnosis of multiple sclerosis.

A. Hypoxemia due to dead space B. Impaired carbon dioxide elimination due to shunting C. Decreased pulmonary arterial pressure due to ventilation-perfusion (V/Q) mismatch D. Decreased pulmonary compliance due to stiffness

Correct Answer is D

Explanation

Choice A Reason:

Hypoxemia due to dead space is not appropriate. Dead space refers to areas of the lung where ventilation occurs but no perfusion takes place. In ARDS, hypoxemia typically occurs due to ventilation-perfusion (V/Q) mismatch and shunting rather than dead space.

Choice B Reason:

Impaired carbon dioxide elimination due to shunting is not appropriate. Shunting occurs when blood bypasses ventilated alveoli, leading to inadequate gas exchange. In ARDS, shunting contributes to hypoxemia, but it doesn't directly impair carbon dioxide elimination.

Choice C Reason:

Decreased pulmonary arterial pressure due to ventilation-perfusion (V/Q) mismatch is incorrect. V/Q mismatch occurs when ventilation and perfusion are mismatched in different areas of the lung. This leads to areas of low ventilation (dead space) and areas of low perfusion (shunting). V/Q mismatch contributes to hypoxemia in ARDS but does not typically lead to decreased pulmonary arterial pressure.

Choice D Reason:

Decreased pulmonary compliance due to stiffness is correct. This is a characteristic feature of ARDS. The inflammation and damage to the alveoli cause them to become stiff, reducing pulmonary compliance and impairing lung expansion during ventilation.

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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.)