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

Answer and Explanation

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 D

Explanation

Choice A rationale
Monitoring volume status is important in managing increased ICP, but it is not a direct intervention to reduce ICP78.
Choice B rationale

Ensuring proper ventriculostomy transducer levels is important in monitoring ICP, but it is not a direct intervention to reduce ICP78.
Choice C rationale
Managing sedation can help control agitation and excessive muscular activity, which can potentially increase ICP. However, it is not a direct intervention to reduce ICP78.
Choice D rationale
Elevating the head of the bed 15 degrees can help promote venous drainage, enhance cerebral perfusion, and reduce ICP78.

A. Pulmonary embolus B. Bacterial translocation C. Deep vein thrombosis D. Myocardial infarction

Correct Answer is B

Explanation

Choice A rationale
Pulmonary embolus is a serious condition that can occur due to prolonged immobility, but it is not directly related to the timing of enteral nutrition in a client with increased intracranial pressure.

Choice B rationale
Bacterial translocation refers to the migration of bacteria from the gut to other areas of the body. Early enteral nutrition (within 24 to 48 hours) in critically ill patients can help maintain the integrity of the gut mucosa and prevent bacterial translocation. Therefore, starting enteral nutrition within this timeframe can help prevent bacterial translocation.
Choice C rationale
Deep vein thrombosis, like pulmonary embolus, is a risk due to immobility but is not directly related to the timing of enteral nutrition.
Choice D rationale
Myocardial infarction is a cardiac event that could be related to overall cardiovascular health, stress, or specific injury to the cardiac muscle. It is not directly prevented by the initiation of enteral nutrition.

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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.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has increased intracranial pressure. Which of the following interventions should the nurse plan to include in the plan of care?

Correct Answer is D

Explanation

A nurse is planning care for a client who has increased intracranial pressure. The nurse should understand that enteral nutrition should begin within 24 to 48 hr to help prevent which of the following complications?

Correct Answer is B

Explanation

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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.)