An 18-year-old client was hit in the head with a baseball during practice. When discharging him to the care of his mother, the nurse gives which of the following instructions?
A. “Watch him for a keyhole pupil the next 24 hours.”
B. “Expect profuse vomiting for 24 hours after the injury.”
C. “Wake him every hour and assess his orientation to person, time, and place.”
D. “Notify the physician immediately if he has a headache.”
Correct Answer: C. “Wake him every hour and assess his orientation to person, time, and place.”
Changes in LOC may indicate expanding lesions such as subdural hematoma; orientation and LOC are frequently assessed for 24 hours. Orient the patient to surroundings, staff, necessary activities as needed. Present reality concisely and briefly. Avoid challenging illogical thinking—defensive reactions may result. Increased orientation ensures greater degree of safety for the patient.
Option A: A keyhole pupil is found after iridectomy. Colobomas may be present in one or both eyes and, depending on their size and location, can affect a person’s vision. Colobomas affecting the iris, which result in a “keyhole” appearance of the pupil, generally do not lead to vision loss.
Option B: Profuse or projectile vomiting is a symptom of increased ICP and should be reported immediately. Projectile vomiting, particularly on arising from sleep, may be due to increased intracranial pressure. Generalized raised intracranial pressure itself causes few clinical changes except for headache, vomiting and papilledema, but tissue shifts at a distance from the mass produce the dramatic signs traditionally associated with raised ICP.
Option D: A slight headache may last for several days after concussion; severe or worsening headaches should be reported. Of particular importance in a patient’s history is whether the patient has a history of any prior concussions. “A greater number, severity, and duration of symptoms” with previous concussions can be predictive of longer recovery time. Finally, pre-existing mood disorders, learning disorders, sleep disturbances, and migraine headaches may also impact the management of a concussion.
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