An ambulance medic reported a client was on the way with a ...

[ec501234]

An ambulance medic reported a client was on the way with a traumatic brain injury (TBI). Which of the following symptoms would the nurse expect this client to display?
 
  a. Blurred vision and a headache
  b. Hypotension and tachycardia
  c. Irregular heart rate
  d. Fecal incontinence

Question 2

A nurse completed the health assessment but needed to use the elderly woman's bathroom. The nurse noticed perineal pads under the sink. Which of the following questions would the nurse most likely ask the woman?
 
  a. Can you tell me why you need to have perineal pads?
  b. Do you know how to do Kegel exercises to help control your urine?
  c. Does another woman live with you or visit often?
  d. Why do you have perineal pads? Are you bleeding down there?

[verrinzo]

Answer to Question 1

ANS: A
TBI symptoms may be mild, moderate, or severe. Symptoms of mild TBI include headache, confusion, light-headedness, dizziness, blurred vision or tired eyes, ringing in the ears, bad taste in the mouth, fatigue or lethargy, and a change in sleep patterns or thinking. Moderate or severe TBI may demonstrate the same symptoms as mild TBI plus a headache that gets worse or does not go away, repeated vomiting or nausea, convulsions or seizures, an inability to awaken from sleep, dilation of one or both pupils of the eyes, slurred speech, weakness or numbness in the extremities, loss of coordination, and increased confusion, restlessness, or agitation. The other symptoms are not indicative of TBI.

Answer to Question 2

ANS: B
Because the woman did not mention incontinence, it may be assumed to be very embarrassing. Therefore, the nurse should matter-of-factly address urine control problems by suggesting a self-help intervention of Kegel exercises. It may be assumed that the nurse, having completed a health assessment, would know about bleeding, as well as frequent visitors or family nearby.

[ec501234]

TYSM

[dantucker]

Wow, this really help