A patient presents to the emergency department with signs of an epidural hematoma. Which manifestation is characteristic of this type of hematoma?

Loss of consciousness greater than 30 minutes following injury.

Lucid intervals followed by momentary unconsciousness.

Memory loss of the prior day's activities.

Amnesia of the injury event.

Answer and Explanation

The Correct Answer is B

Choice A reason:

Loss of consciousness greater than 30 minutes following injury can occur in various types of head injuries but is not specific to epidural hematomas.

Choice B reason:

Lucid intervals followed by momentary unconsciousness are characteristic of epidural hematomas. Patients with epidural hematomas often experience a period of lucidity following the initial loss of consciousness, followed by a rapid decline in mental status as the hematoma enlarges and increases intracranial pressure.

Choice C reason:

Memory loss of the prior day's activities can occur with various head injuries but is not specific to epidural hematomas.

Choice D reason:

Amnesia of the injury event is common in head injuries but is not specific to epidural hematomas. The hallmark of epidural hematomas is the pattern of lucid intervals followed by rapid deterioration.

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Correct Answer is ["C","D","E"]

Explanation

Choice A reason:

Soaking the pin sites with alcohol pads is not recommended as it can dry out the skin and increase the risk of infection. Pin site care typically involves using saline or other recommended solutions to clean the area gently.

Choice B reason:

Removing the vest when bathing the patient is not recommended. The vest provides stability and support for the spinal fracture, and removing it can compromise the patient's safety. Alternative methods should be used to maintain hygiene without removing the vest.

Choice C reason:

Assessing the chest and back for skin breakdown is crucial in patients with a halo device to prevent pressure ulcers and other skin issues. Regular assessment helps identify any potential problems early.

Choice D reason:

Assessing pin sites frequently for signs of infection is essential to prevent complications. Infection at the pin sites can lead to serious issues, and frequent monitoring ensures any signs of infection are caught and treated promptly.

Choice E reason:

Taping a halo wrench to the vest is important for emergencies. The wrench is necessary to quickly remove the halo device if needed in an emergency situation, such as if the patient requires resuscitation.

A. Respiratory rate is 26. B. +1 pedal pulses. C. Body temperature is 36.8°C (rectal). D. Urine output is greater than 40 cc/hr.

Correct Answer is D

Explanation

Choice A reason:

While an increased respiratory rate can indicate a compensatory response to shock, it does not directly measure tissue perfusion. It suggests the body is attempting to improve oxygen delivery, but it is not a definitive indicator of adequate tissue perfusion.

Choice B reason:

+1 pedal pulses can indicate decreased perfusion to the extremities, but they do not provide comprehensive information about overall tissue perfusion. Peripheral pulses can be weak in shock due to vasoconstriction and poor circulation, but they are not the most reliable indicator of tissue perfusion.

Choice C reason:

Body temperature is not a direct measure of tissue perfusion. While it is important to monitor, changes in temperature can result from various factors and do not specifically reflect the adequacy of tissue perfusion.

Choice D reason:

Urine output greater than 40 cc/hr is a key indicator of adequate tissue perfusion. The kidneys are highly sensitive to changes in perfusion, and adequate urine output suggests that the kidneys are receiving sufficient blood flow to filter and excrete waste products. Monitoring urine output is a standard practice in assessing tissue perfusion and overall fluid balance in shock patients.

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A patient presents to the emergency department with signs of an epidural hematoma. Which manifestation is characteristic of this type of hematoma?

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Naxlex Comprehensive Predictor Exams

The nurse is preparing to care for a patient with a spinal fracture who has a halo device in place. The nurse plans to implement the following orders:

Correct Answer is ["C","D","E"]

Explanation

Which assessment of a patient in shock would give the nurse the most valuable information to determine there is adequate tissue perfusion?

Correct Answer is D

Explanation

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