Physiological Adaptation Q 191

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Herbert, a 45-year-old construction engineer is brought to the hospital unconscious after falling from a 2-story building. When assessing the client, the nurse would be most concerned if the assessment revealed:

  

     A. Reactive pupils

     B. A depressed fontanel

     C. Bleeding from ears

     D. An elevated temperature

    

    

Correct Answer: C. Bleeding from ears

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The nurse needs to perform a thorough assessment that could indicate alterations in cerebral function, increased intracranial pressures, fractures, and bleeding. Bleeding from the ears occurs only with basal skull fractures that can easily contribute to increased intracranial pressure and brain herniation.

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Option A: The normal pupil size varies from 2 to 4 mm in diameter in bright light to 4 to 8 mm in the dark. The pupils are generally equal in size. They constrict to direct illumination and to illumination of the opposite eye. The pupil dilates in the dark. Both pupils constrict when the eye is focused on a near object.

Option B: The anterior fontanelle remains soft until about 18 months to 2 years of age. The posterior fontanelle usually closes first, during the first several months of an infant’s life.

Option D: Hypothermic trauma patients are less likely to survive their injuries when compared to similar patients who are normothermic. Hypothermia in conjunction with metabolic acidosis and impair coagulation creates a “lethal triad”, which significantly worsens the chances of recovery from a critical injury.

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