A young adult client involved in a minor motor vehicle collision three weeks ago reports having a headache, blurred vision, vertigo, and nausea. The client's vital signs are within normal limits, and a nutrition history reveals that the client is eating very little because of being concerned about paying for car repairs. Priority nursing care should be based on which nursing problem?
High risk for injury related to increased intracranial pressure.
Alteration in comfort related to motor vehicle collision.
Alteration in nutrition related to poor dietary intake.
Anxiety related to unknown outcome of automobile repairs.
The Correct Answer is A
A. The client's symptoms of headache, blurred vision, vertigo, and nausea, even without abnormal vital signs, are suggestive of potential neurological complications from a head injury, such as increased intracranial pressure (ICP). This requires immediate attention and evaluation.
B. While the client is experiencing discomfort, it is secondary to the potential neurological issue.
C. The client's nutritional status is a concern, but it is not the priority at this time, given the potential neurological implications of the client's symptoms.
D. While the client's anxiety is understandable, it is not the primary concern given the more immediate health risk.
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Related Questions
Correct Answer is C
Explanation
A. While it's important to monitor for complications, this is not a typical initial instruction for a soft tissue injury.
B. Early range of motion exercises are generally not recommended for acute soft tissue injuries, as they can increase swelling and pain.
C. This is the correct instruction. Applying ice to the injured area helps reduce swelling and pain. It should be applied intermittently to prevent tissue damage from excessive cold.
D. Heat is typically used in the later stages of healing to promote blood flow and relaxation, but continuous heat application can be harmful in the acute phase.
Correct Answer is {"dropdown-group-1":"C","dropdown-group-2":"C"}
Explanation
Based on the information collected, the client is likely experiencing Hypoxia related to Tonic clonic seizure
Rationale
The severe drop in oxygen saturation and the observation of violent jerking movements are consistent with a tonic-clonic seizure, which can be precipitated or exacerbated by significant hypoxia.
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