A client whose heart monitor shows sinus tachycardia, is apneic and has no palpable pulses. What action should the nurse ta next?

Start cardiopulmonary resuscitation (CPR)

Provide supplemental 02 via non-rebreather mask

Give atropine per agency dysrhythmia protocol

Perform synchronized cardioversion

Answer and Explanation

The Correct Answer is A

A. Start cardiopulmonary resuscitation (CPR): The client is apneic with no palpable pulses, indicating cardiac arrest. The immediate priority is to begin CPR to provide chest compressions and ventilation, which is essential for maintaining circulation and oxygenation.

B. Provide supplemental O2 via non-rebreather mask: While oxygen is crucial, the primary concern is restoring circulation and ensuring oxygenation through CPR. Oxygen administration alone won't address the lack of circulation, CPR should be started first.

C. Give atropine per agency dysrhythmia protocol: Atropine is typically used for bradycardia, not sinus tachycardia. The client's apneic state and lack of pulses indicate a more severe issue, such as cardiac arrest, which requires immediate CPR, not atropine.

D. Perform synchronized cardioversion: Synchronized cardioversion is used for specific arrhythmias such as atrial fibrillation or supraventricular tachycardia with a pulse. Since the client has no pulse, defibrillation (if indicated) or CPR should be initiated first, not synchronized cardioversion.

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Correct Answer is B

Explanation

A. Burr hole: A burr hole is a small hole drilled into the skull to relieve pressure or drain fluid, but it is not a type of brain injury. It is a medical intervention, not an injury description like coup, contrecoup.

B. A coup, contrecoup injury: A coup, contrecoup injury occurs when the brain is bruised in two areas: at the site of impact (coup) and on the opposite side of the brain (contrecoup). This is consistent with the patient's CT and MRI findings of bruising in both the anterior and posterior parts of the brain.

C. Concussion: A concussion is a mild traumatic brain injury that typically causes temporary confusion or loss of consciousness. However, a concussion does not typically present with visible bruising on both the anterior and posterior areas of the brain.

D. Hematoma: A hematoma refers to a collection of blood outside of blood vessels, which can occur in the brain after trauma. While a hematoma may result from brain bruising, it is not a description of the injury pattern like coup, contrecoup.

A. An initial loss of consciousness followed by a coherent period and a subsequent loss of consciousness B. Narrowing pulse pressure with tachycardia C. Drainage of clear fluid from the ears and nose D. Extensive swelling under the eyes

Correct Answer is A

Explanation

A. An initial loss of consciousness followed by a coherent period and a subsequent loss of consciousness: An epidural hematoma typically presents with a brief loss of consciousness, followed by a lucid period, then a second loss of consciousness. This pattern is a hallmark sign due to rapid pressure buildup from the blood.

B. Narrowing pulse pressure with tachycardia: Narrowing pulse pressure and tachycardia are not associated with an epidural hematoma. More commonly, widening pulse pressure and bradycardia (Cushing’s triad) are seen in severe cases of increased intracranial pressure.

C. Drainage of clear fluid from the ears and nose: Drainage of clear fluid from the ears and nose may suggest CSF leakage, typically due to a skull fracture. This is not specific to an epidural hematoma, which primarily involves bleeding between the dura and skull.

D. Extensive swelling under the eyes: "Raccoon eyes" can be seen with basal skull fractures, but it is not specific to epidural hematomas. The hallmark manifestation is the consciousness pattern described in option A.

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A client whose heart monitor shows sinus tachycardia, is apneic and has no palpable pulses. What action should the nurse ta next?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Your patient is currently unconscious after a bad car accident. After a CT scan and MRI are performed on the patient's head and neck, there are signs of brain bruising on both the anterior and posterior portions of the brain. This should be documented as signs of what?

Correct Answer is B

Explanation

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Correct Answer is A

Explanation

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