Which observations by the nurse are representative of the symptomology of an epidural hematoma (EDH)? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply
1. History of unconsciousness immediately after trauma
2. Muscle weakness on the side opposite the head injury
3. Rapid deterioration in level of consciousness
4. Period of lucidity prior to onset of symptoms
5. Dilated pupil on the same side as the injury
1,3,4,5
Rationale 1: The classic clinical presentation of EDH is characterized by an immediate posttraumatic period of unconsciousness, followed by a lucid interval, which can last from minutes to hours.
Rationale 2: Hemiparesis (muscle weakness) of the contralateral arm and leg (opposite side from the injury) may be present with an acute subdural hematoma.
Rationale 3: A rapid deterioration in the level of consciousness may occur unexpectedly.
Rationale 4: The classic clinical presentation of EDH is characterized by an immediate posttraumatic period of unconsciousness, followed by a lucid interval, which can last from minutes to hours.
Rationale 5: Possible signs and symptoms include an enlarging pupil on the same side as the injury (ipsilateral).
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