A nurse is caring for an adolescent who was admitted to the emergency department with a minor head injury. Which of the following findings should the nurse expect?
Explanation & Rationale
A. Fixed and dilated pupils: Fixed and dilated pupils typically indicate severe brain injury or increased intracranial pressure, which is unlikely in a minor head injury. These findings are more characteristic of significant trauma or neurological compromise rather than an expected symptom in minor cases. B. Fever: Fever is not a direct consequence of a minor head injury. While infection or other complications can cause fever, it is not an expected finding immediately following a minor head trauma in an otherwise healthy adolescent. C. Retinal hemorrhages: Retinal hemorrhages are usually associated with non-accidental trauma or severe head injuries. In a minor head injury from a typical accident, retinal hemorrhages are not expected and would warrant further investigation for other causes. D. Vomiting: Vomiting is a common and expected symptom following a minor head injury, often due to transient increases in intracranial pressure or vestibular disturbance. It is frequently observed in adolescents after mild concussions and should be monitored for severity and frequency.