A nurse is the first person on the scene of a motor vehicle accident.
The victim was the driver and is in the driver's seat unconscious.
The driver is breathing, has a pulse, and has minor lacerations on the head and face.
What action should the nurse implement first?

Stabilize the cervical spine until help arrives.

Control any external bleeding.

Use the head tilt chin lift method to maintain the airway.

Do not move the victim from the accident.

Answer and Explanation

The Correct Answer is A

Choice A rationale

Stabilizing the cervical spine prevents further spinal injury in case of vertebral damage, which is a priority when managing trauma patients until specialized medical care becomes available.

Choice B rationale

While controlling bleeding is essential, it is secondary to stabilizing the cervical spine since the airway and neurological protection take precedence in trauma protocols.

Choice C rationale

The head tilt chin lift method should not be used if cervical spine injury is suspected, as it may exacerbate potential damage to the vertebrae or spinal cord.

Choice D rationale

While not moving the victim is critical, stabilization of the cervical spine is the primary intervention to prevent further injury before emergency assistance arrives.

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Correct Answer is B

Explanation

Choice A rationale

Ventriculostomies are inserted directly through the skull into the ventricles, not via the femoral artery. This method provides direct access to cerebrospinal fluid for drainage and pressure monitoring.

Choice B rationale

Ventriculostomies are placed to monitor intracranial pressure and drain excess cerebrospinal fluid, managing conditions like hydrocephalus or elevated intracranial pressure following brain injury or surgery.

Choice C rationale

An EEG monitors electrical brain activity but is unrelated to ventriculostomy placement. Ventriculostomy focuses on fluid drainage and pressure management, not on electrical diagnostic procedures.

Choice D rationale

Ventriculostomies carry a significant risk of infection due to the invasive nature of the procedure. Proper aseptic technique is critical to minimizing, not eliminating, the risk of infection.

A. Elevate the head of the bed 30-45 degrees. B. Perform serial neurologic assessments while hospitalized. C. Suction frequently to prevent development of pneumonia. D. Administer sedatives/pain medications per orders. E. Stimulate the patient with TV, music, lights, and family at bedside.

Correct Answer is ["A","B","D"]

Explanation

Choice A rationale

Elevating the head 30-45 degrees aids in venous drainage and reduces intracranial pressure. It also prevents cerebral edema by improving cerebrospinal fluid outflow without compromising cerebral perfusion.

Choice B rationale

Serial neurological assessments help monitor for changes in intracranial pressure, enabling early intervention. They ensure timely recognition of symptoms indicating worsening pressure or neurological deterioration.

Choice C rationale

Frequent suctioning increases intracranial pressure due to stimulation of the vagus nerve, leading to coughing or gagging. It can also induce hypoxia, further exacerbating intracranial pressure.

Choice D rationale

Administering sedatives and pain medications reduces cerebral metabolic rate and sympathetic stimulation, which in turn prevents spikes in intracranial pressure. It also helps prevent agitation and discomfort in the patient.

Choice E rationale

Stimulating the patient with TV, music, lights, and family increases sensory input, which can elevate intracranial pressure. Overstimulation can cause agitation, raising intracranial pressure further.

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A nurse is the first person on the scene of a motor vehicle accident.The victim was the driver and is in the driver's seat unconscious.The driver is breathing, has a pulse, and has minor lacerations on the head and face.What action should the nurse implement first?

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Naxlex Comprehensive Predictor Exams

The nurse is educating on the placement of a ventriculostomy (intraventricular catheter) to the family of a patient diagnosed with a brain injury.The nurse states, "The ventriculostomy is placed:

Correct Answer is B

Explanation

The nurse has established a goal to maintain intracranial pressure (ICP) within the normal range for a patient with an acute head injury.Which actions should the nurse take to achieve this goal? (Select All that Apply.)

Correct Answer is ["A","B","D"]

Explanation

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A nurse is the first person on the scene of a motor vehicle accident.
The victim was the driver and is in the driver's seat unconscious.
The driver is breathing, has a pulse, and has minor lacerations on the head and face.
What action should the nurse implement first?