A man brings his wife to the emergency department (ED) because she is confused and restless. He tells the nurse that they were in a motor vehicle collision early today and his wife bumped her head on the dashboard. The husband is very concerned about his wife and refuses to leave her bedside. Which intervention is most important for the nurse to implement?

Orient the client to her surroundings.

Allow husband to stay at bedside.

Implement seizure precautions.

Assess for drainage from ears or nose.

Answer and Explanation

The Correct Answer is D

Rationale:
A. Orient the client to her surroundings: While orientation is helpful for confusion, the client’s restlessness and confusion could indicate increasing intracranial pressure or cerebral bleeding, which require immediate physical assessment rather than reassurance.

B. Allow husband to stay at bedside: Allowing the husband to remain can provide emotional support, but this is not the priority when assessing for potentially life-threatening neurological changes. Emotional comfort is secondary to detecting and managing complications of head trauma.

C. Implement seizure precautions: Seizure precautions are appropriate for clients with head injuries but should follow a focused neurological assessment. Detecting cerebrospinal fluid (CSF) leakage or signs of skull fracture takes precedence because it indicates a severe brain injury requiring urgent intervention.

D. Assess for drainage from ears or nose: Clear or bloody drainage may indicate CSF leakage due to a basilar skull fracture. Identifying this finding early is critical to prevent infection, monitor for increased intracranial pressure, and guide emergent management, making this the most important immediate nursing action.

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Correct Answer is B

Explanation

Rationale:
A. Administer epinephrine IV: Epinephrine is given after the first unsuccessful defibrillation attempt during cardiac arrest management. It enhances coronary and cerebral perfusion pressures, but it is not the initial intervention when ventricular fibrillation is first identified.

B. Provide immediate defibrillation: Ventricular fibrillation is a pulseless, life-threatening rhythm that requires immediate defibrillation to restore an organized cardiac rhythm. Early defibrillation within minutes of onset greatly increases the chance of survival and successful resuscitation.

C. Prepare for synchronized cardioversion: Synchronized cardioversion is used for organized tachyarrhythmias such as supraventricular tachycardia or atrial fibrillation with a pulse. It is inappropriate for ventricular fibrillation because there is no coordinated electrical activity to synchronize with.

D. Give an IV bolus of amiodarone: Amiodarone is administered after defibrillation and epinephrine if VF persists. It stabilizes the cardiac membrane and reduces recurrent dysrhythmias, but drug therapy follows defibrillation in the resuscitation sequence.

A. Transcutaneous pacing. B. Mechanical ventilation. C. Chest tube insertion. D. Synchronized cardioversion.

Correct Answer is A

Explanation

Rationale:
A. Transcutaneous pacing: The ECG rhythm demonstrates a third-degree (complete) heart block. This results in severe bradycardia and hypotension (80/50 mm Hg), placing the client at risk for syncope and cardiac arrest. Transcutaneous pacing is the immediate intervention to maintain cardiac output until a permanent pacemaker can be placed.

B. Mechanical ventilation: Although hypotension and bradycardia can lead to hypoxia, the client’s issue is primarily electrical conduction failure, not respiratory compromise. Ventilatory support would not correct the underlying cause of hemodynamic instability.

C. Chest tube insertion: Chest tube insertion is indicated for pneumothorax or hemothorax, not cardiac conduction abnormalities. There is no evidence of respiratory distress or pleural injury requiring this intervention.

D. Synchronized cardioversion: Cardioversion is used for tachydysrhythmias such as atrial fibrillation or supraventricular tachycardia. It is contraindicated in complete heart block, where electrical pacing not shock is required to restore effective cardiac rhythm and perfusion

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Naxlex Comprehensive Predictor Exams

A client's telemetry monitor indicates ventricular fibrillation (VF). Which should the nurse do first?

Correct Answer is B

Explanation

A client admitted to the telemetry unit with a diagnosis of syncopal episodes has a sitting blood pressure of 80/50 mm Hg, a regular apical pulse, and a cardiac rhythm as shown on the monitor. The nurse should prepare the client for which procedure?

Correct Answer is A

Explanation

A client who sustained a head injury is alert and oriented to person, place, time, and situation, moves all extremities on command, has equal muscle strength bilaterally, and pupils are reactive to light. Which action should the nurse implement next?

Patient Data Exhibits For each of the findings listed, click to indicate which are consistent with the disease process of aortic aneurysm versus gastric cancer. Each column must have at least one response option selected.

An unconscious client is demonstrating pulseless ventricular tachycardia (PVT).The nurse checks the client's pulse and begins cardiopulmonary resuscitation (CPR). The defibrillator and crash cart arrive at the bedside and the client is shocked. Which action should the nurse implement next?

The nurse is completing a neurological assessment on a client with a closed head injury. The Glasgow Coma Scale (GCS) score was 13 on admission. It is now assessed at 6. Which is the priority nursing intervention based on the client's current GCS?

Exhibits Which of the following findings should the nurse prioritize?

Patient Data Exhibits Complete the diagram by dragging from the choices area to specify which condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client's progress.