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.
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Correct Answer is C
Explanation
Choice A rationale
A contrecoup injury is indeed a “true” injury. It occurs on the side of the brain opposite to the point of impact and can have severe consequences, including brain damage. Therefore, this statement is incorrect.
Choice B rationale
The severity and healing time of contrecoup injuries can vary greatly depending on the force and location of the impact, as well as individual health factors. It’s not accurate to say that contrecoup injuries are generally less severe and heal more quickly over time.
Choice C rationale
This statement is correct. A coup injury refers to the brain damage that occurs directly under the point of impact, while a contrecoup injury occurs on the opposite side of the brain from
where the head is struck. These injuries can occur separately or together, but if the blow is strong enough, they usually appear together.
Choice D rationale
The sequence of coup and contrecoup injuries is not as this choice describes. The coup injury happens at the point of impact, and the contrecoup injury happens when the brain rebounds and hits the opposite side of the skull. Both types of injuries can impact the brain’s blood supply.
Correct Answer is C
Explanation
Choice A rationale
Peripheral neuropathy is a result of damage to the peripheral nerves and is often associated with conditions like diabetes, infections, and traumatic injuries. It typically causes chronic pain, characterized by a burning or tingling sensation, rather than acute pain.
Choice B rationale
Fibromyalgia is a chronic disorder characterized by widespread musculoskeletal pain, fatigue, and tenderness in localized areas. It is not an example of acute pain.
Choice C rationale
A surgical incision is a common cause of acute pain. Pain from a surgical incision occurs suddenly, usually as a result of tissue damage from the surgery, and it resolves once the tissue heals.
Choice D rationale
Rheumatoid arthritis is a chronic inflammatory disorder that can affect more than just your joints. It typically causes chronic pain, not acute pain.
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