A client who was involved in a motor vehicle collision while riding a motorcycle without wearing a helmet, is brought the emergency department (ED) by emergency medical services (EMS). Which assessment should the nurse obtain first?
Degree of pain using a 10 point scale.
Pulse and blood pressure.
Balance and coordination.
Bilateral pupillary reaction to light.
The Correct Answer is B
A. Degree of pain using a 10-point scale. Pain assessment is important, but it is not the priority in an emergency trauma situation. Clients involved in motor vehicle collisions (MVCs) without a helmet are at high risk for life-threatening injuries, including hemorrhage and shock. The nurse must first assess vital signs to determine hemodynamic stability.
B. Pulse and blood pressure. The primary concern in trauma patients is circulation and perfusion. Assessing pulse and blood pressure helps determine if the client is experiencing shock, hemorrhage, or traumatic brain injury (TBI)-related autonomic dysfunction. In trauma resuscitation, the ABCs (Airway, Breathing, Circulation) guide assessment priorities, making circulatory status the first concern after ensuring airway patency.
C. Balance and coordination. A neurological assessment for balance and coordination is not a priority in a critically injured trauma patient. Severe injuries, including intracranial hemorrhage, cervical spine trauma, or internal bleeding, must be ruled out before assessing fine motor function.
D. Bilateral pupillary reaction to light. Pupillary response is part of a neurological assessment and is crucial in identifying traumatic brain injury. However, vital signs must be assessed first to determine hemodynamic stability, as untreated shock or hemorrhage can lead to rapid deterioration or death.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Junctional tachycardia: Junctional tachycardia originates from the AV node, typically with a narrow QRS, absent or inverted P waves, and a rate of 100–180 bpm. The strip does not show these features.
B. Second-degree Type II AV block (3:1).Type II AV block (Mobitz II) shows dropped QRS complexes with constant PR intervals before conducted beats. This strip does not show missing QRS complexes in a 3:1 pattern.
C. Ventricular fibrillation. VF is characterized by a chaotic, disorganized rhythm with no discernible P waves, QRS complexes, or T waves, completely different from this organized flutter pattern.
D. Atrial flutter is characterized by regular, rapid atrial depolarizations (flutter waves) at a rate of 250–350 bpm. These waves create a "sawtooth" pattern on the ECG.The ventricular response may be regular or irregular, depending on AV conduction. This is different from atrial fibrillation (which has irregularly irregular R-R intervals and no discrete P waves).
Correct Answer is C
Explanation
A. Narrowed pulse pressure, presence of 3+ femoral pulses, apneic episodes. Narrowed pulse pressure is consistent with hypovolemic shock, but 3+ femoral pulses are not expected, as shock leads to weak, thready pulses due to reduced perfusion. Apneic episodes typically occur in the late stages of shock, not in the early or progressive stages.
B. Widening pulse pressure, muffled heart sounds, presence of atrial gallop. A widening pulse pressure and muffled heart sounds are more indicative of cardiac tamponade, not hypovolemic shock. Hypovolemic shock is characterized by a narrowing pulse pressure due to a drop in systolic blood pressure while diastolic pressure remains relatively stable.
C. Increased heart rate, lowered systolic reading, peripheral extremity mottling. Tachycardia is an early compensatory response to hypovolemia as the body attempts to maintain cardiac output. As shock progresses, systolic blood pressure drops due to inadequate circulating volume. Peripheral extremity mottling occurs as the body shunts blood to vital organs, reducing perfusion to the skin. These signs are characteristic of progressive hypovolemic shock.
D. Irregular heart rate, elevated diastolic reading, increased respiratory rate. An irregular heart rate is not a primary indicator of hypovolemic shock. While respiratory rate increases in response to decreased oxygen delivery, an elevated diastolic reading is uncommon, as diastolic pressure tends to stay stable or decrease slightly with ongoing hypovolemia.
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