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:

Dyspnea is not commonly seen in other chronic conditions of the aging older adult: This statement is incorrect. Dyspnea, or difficulty breathing, can occur in various chronic conditions commonly seen in aging adults, such as chronic obstructive pulmonary disease (COPD), heart failure, and pulmonary fibrosis, among others. Dyspnea can be a symptom of respiratory or cardiovascular issues and is not exclusive to asthma.

Choice B Reason:

Aging is associated with decreased sensitivity to medications: This statement is generally incorrect. Aging can affect drug metabolism and clearance, leading to changes in medication sensitivity. Older adults may have altered pharmacokinetics and pharmacodynamics, which can increase their sensitivity to certain medications, particularly those with sedative or CNS depressant effects. This increased sensitivity can potentially increase the risk of adverse drug reactions.

Choice C Reason:

Adverse reactions to medications in the aging older adult are lower: This statement is incorrect. While some physiological changes associated with aging may decrease the risk of adverse drug reactions, such as decreased renal function and altered drug metabolism, older adults are still at risk for adverse drug reactions due to factors such as polypharmacy, drug interactions, and increased sensitivity to medications.

Choice D Reason:

Physiological changes in the respiratory system can mimic the presence of airway obstruction: This statement is true. Physiological changes in the aging respiratory system, such as decreased lung elasticity, increased chest wall stiffness, and reduced respiratory muscle strength, can mimic the symptoms of airway obstruction seen in conditions like asthma or COPD. These changes can lead to decreased lung function, reduced exercise tolerance, and increased susceptibility to respiratory infections.

A. Easily getting back to sleep after awakening B. Many episodes of apnea per night C. Loud snort after breathing cessation D. 10 seconds or longer of breathing cessation 10 seconds or longer of breathing cessation E. Daytime sleepiness F. Frequent, loud snoring

Correct Answer is ["B","C","D","E","F"]

Explanation

Choice A Reason:

Easily getting back to sleep after awakening is incorrect. This is not typically a manifestation of obstructive sleep apnea. Instead, individuals with OSA often experience fragmented sleep due to frequent awakenings caused by apnea episodes.

Choice B Reason:

Many episodes of apnea per night is correct. Yes, individuals with obstructive sleep apnea experience many episodes of apnea (complete cessation of breathing) or hypopnea (partial obstruction of airflow) per night. These episodes can occur multiple times throughout the night, disrupting normal sleep patterns.

Choice C Reason:

Loud snort after breathing cessation is correct. This is a characteristic manifestation of obstructive sleep apnea. Individuals with OSA often make choking, snorting, or gasping sounds after a period of breathing cessation as they attempt to resume breathing.

Choice D Reason:

10 seconds or longer of breathing cessation is correct. Yes, breathing cessation episodes in obstructive sleep apnea typically last for 10 seconds or longer. These prolonged episodes of apnea contribute to oxygen desaturation and disrupted sleep.

Choice E Reason:

Daytime sleepiness is correct. Yes, daytime sleepiness is a common symptom of obstructive sleep apnea. Disrupted sleep patterns and frequent awakenings during the night can lead to excessive daytime sleepiness, fatigue, and decreased alertness.

Choice F Reason:

Frequent, loud snoring is correct. Yes, frequent, loud snoring is a hallmark symptom of obstructive sleep apnea. Snoring occurs due to the partial obstruction of airflow in the upper airway during sleep.

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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.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client with asthma. Which of the following statements are true regarding physiological changes of the respiratory system in the aging adult client?

Correct Answer is D

Explanation

Which of the following are manifestations of obstructive sleep apnea? (Select all that apply.) (Select All that Apply.)

Correct Answer is ["B","C","D","E","F"]

Explanation

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A nurse is teaching a group of student nurses about populations at higher risk for multiple sclerosis. Which of the following demographics should be included in the teaching? (Select All that Apply.)

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.)