A nurse is caring for a patient who was involved in a motor vehicle accident.The patient is alert and oriented and reports a loss of consciousness immediately after the accident.
Which of the following additional symptoms should the nurse assess the patient for? (Select All that Apply.)
Pupillary dilation
Persistent headache
Presence of hand tremors
Difficulty waking
Foot drop
Correct Answer : A,B,D
Choice A rationale
Pupillary dilation can be a sign of increased intracranial pressure, which could be a result of a traumatic brain injury following a motor vehicle accident. It’s important to assess for this symptom as it may indicate a serious condition that requires immediate medical attention.
Choice B rationale
Persistent headache is a common symptom following a head injury and can be a sign of a concussion or more serious brain injury. It’s crucial to monitor for this symptom as it can provide important information about the patient’s condition.
Choice C rationale
Presence of hand tremors is not typically associated with a head injury from a motor vehicle accident. While tremors can be a symptom of various neurological conditions, they are not commonly seen immediately after a traumatic head injury.
Choice D rationale
Difficulty waking can be a sign of a serious head injury. It could indicate a concussion or other type of traumatic brain injury. This symptom should be closely monitored as it may require immediate medical intervention.
Choice E rationale
Foot drop is not typically a symptom observed immediately after a motor vehicle accident. It’s more commonly associated with peripheral nerve conditions or stroke, rather than a head injury.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Anhidrosis, or the inability to sweat normally, is a potential side effect of anticholinergic agents. These medications block the action of acetylcholine, a neurotransmitter that stimulates sweat glands among other functions. If a patient taking an anticholinergic agent for Parkinson’s disease experiences anhidrosis, they should report it to their healthcare provider as it can lead to overheating and heat stroke.
Choice B rationale
Tremors are a common symptom of Parkinson’s disease, and anticholinergic medications are often used to help control them. Therefore, while tremors should be monitored, they are not typically a side effect that needs to be reported unless they worsen or become unmanageable.
Choice C rationale
Drooling can be a symptom of Parkinson’s disease, but it is not typically a side effect of anticholinergic medications. In fact, these medications can sometimes cause dry mouth.
Choice D rationale
Rigidity, like tremors, is a common symptom of Parkinson’s disease. Anticholinergic medications can help manage rigidity, so it is not typically a side effect that needs to be reported unless it worsens.
Correct Answer is C
Explanation
Choice A rationale
Trigeminal neuralgia is a chronic pain condition that affects the trigeminal nerve, which carries sensation from your face to your brain. It does not cause a sensation of tightness around the torso.
Choice B rationale
Lhermitte’s sign is a symptom of multiple sclerosis and other neurological conditions where a person feels an electric shock-like sensation running down the spine and into the limbs. It does not cause a sensation of tightness around the torso.
Choice C rationale
The sensation of tightness around the torso in a patient with multiple sclerosis is often referred to as the “MS hug”. It is caused by a lesion or an area of active inflammation within the spinal cord.
Choice D rationale
Paroxysmal spasms are a type of muscle spasm experienced by some people with multiple sclerosis. These spasms are usually painful and involve the muscles of the legs, but they do not cause a sensation of tightness around the torso.
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