The nurse is admitting a patient who was struck by lightning while golfing. Which of the following is the nurse most likely to assess in this patient?
1. confusion and short-term memory loss
2. awake, alert, and oriented
3. nausea and vomiting
4. bilateral equal hand grasps
1
Rationale: Neurological effects are common with electrical and lightning injuries. Since neurological tissue offers low resistance to electrical current it is easily damaged. Patients may experience confusion, exhibit a flat affect, lose the ability to concentrate, or have short-term memory problems. Seizures, headaches, peripheral nerve damage, and loss of muscle strength may also be observed. It is unlikely that the patient will be awake, alert, and oriented. Nausea and vomiting are not associated with electrical injuries caused by lightning. The patient may or may not have bilaterally equal hand grasps.
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