A client was brought to the emergency department after suffering a closed head injury and lacerations around the face due to a hit-run accident. The client is unconscious and has a minimal response to noxious stimuli. Which of the following assessment findings if observed after few hours, should be reported to the physician immediately?
Bruises and minimal edema of the eyelids
Withdrawal of the client in response to painful stimuli
Drainage of a clear fluid from the client's nose
Bleeding around the lacerations
The Correct Answer is C
Rationale:
A. Mild periorbital bruising (“raccoon eyes”) and minimal swelling are common findings after facial trauma and are not immediately life-threatening. These findings should be monitored but do not require urgent reporting unless they worsen significantly or are accompanied by other neurologic changes.
B. Withdrawal to pain is a normal protective reflex and indicates some preserved neurologic function. While ongoing neurologic assessment is important, this response alone does not indicate an acute deterioration that requires immediate physician notification.
C. Clear fluid drainage from the nose may indicate cerebrospinal fluid (CSF) leakage, which suggests a basal skull fracture or dura mater injury. This is a serious complication that increases the risk of meningitis, brain herniation, or other neurologic compromise and must be reported to the physician immediately for prompt evaluation and management.
D. Bleeding from facial lacerations is expected after trauma and can usually be managed with standard wound care. While it should be monitored and treated, it is not as urgent as signs of CSF leakage or neurologic deterioration.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Rationale:
A. Asystole is a non-shockable rhythm, meaning defibrillation is not indicated. According to ACLS guidelines, the priority is to continue high-quality CPR and administer epinephrine 1 mg IV/IO every 3–5 minutes while identifying and treating reversible causes (H’s and T’s). Immediate interventions focus on supporting circulation and attempting to restore a perfusing rhythm.
B. Stopping CPR is never recommended in asystole unless death is confirmed or resuscitation is deemed futile. Continuous high-quality CPR is critical to maintain perfusion to vital organs.
C. Synchronized cardioversion is used for unstable tachyarrhythmias, such as atrial fibrillation or supraventricular tachycardia with a pulse. It is not indicated for asystole, which is a pulseless rhythm.
D. Defibrillation is reserved for shockable rhythms, such as ventricular fibrillation (VF) or pulseless ventricular tachycardia (pVT). Asystole does not respond to electrical shock, so attempting defibrillation delays other life-saving interventions.
Correct Answer is C
Explanation
Rationale:
A. In a mass casualty incident, immediate action is required. Waiting for instructions could delay life-saving interventions and compromise patient outcomes. Nurses and first responders must act quickly based on established triage protocols.
B. While individualized care is ideal in standard clinical settings, during an MCI it is not practical due to limited resources and the number of patients. The focus must be on rapid assessment and stabilization of those most critically injured.
C. The priority in a mass casualty incident is to quickly assess and categorize patients based on the severity of injuries using triage systems like START (Simple Triage and Rapid Treatment). This ensures that life-saving resources are allocated to those who are most likely to benefit and prevents preventable deaths.
D. Equal allocation without regard to injury severity can result in critically injured patients not receiving timely care, increasing mortality. Resource allocation in MCIs is based on medical need and survivability, not equality.
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