A patient with massive trauma and possible spinal cord injury is admitted to the emergency department. The nurse suspects that the patient may be experiencing neurogenic shock based on which assessment finding?

Cool, clammy skin

Hypotension

Bradycardia

Decrease urinary output

Answer and Explanation

The Correct Answer is C

A. Cool, clammy skin: Cool, clammy skin is characteristic of hypovolemic or cardiogenic shock due to peripheral vasoconstriction. In neurogenic shock, loss of sympathetic tone causes vasodilation, so the skin is typically warm and dry rather than cool and clammy.

B. Hypotension: Hypotension is present in neurogenic shock due to systemic vasodilation and relative hypovolemia. While it is an important finding, it is not specific for neurogenic shock and can be seen in multiple types of shock, making it less definitive as a distinguishing feature.

C. Bradycardia: Neurogenic shock involves loss of sympathetic innervation below the level of spinal cord injury, resulting in unopposed parasympathetic stimulation. This leads to bradycardia in combination with hypotension, a hallmark finding that differentiates neurogenic shock from other shock types, which usually cause tachycardia.

D. Decreased urinary output: Oliguria may occur in neurogenic shock due to hypotension and reduced renal perfusion. However, it is a secondary effect rather than a primary diagnostic sign. Early recognition relies on the combination of hypotension with bradycardia and vasodilation.

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Correct Answer is D

Explanation

A. Provide for delivery of 100% oxygen to the lungs under pressure: PEEP does not specifically deliver 100% oxygen; rather, it maintains alveolar patency at end expiration. Oxygen concentration is set separately on the ventilator.

B. Prevent the fibrotic infiltration of the lung tissue: PEEP does not directly prevent fibrosis. ARDS-related fibrosis is a long-term complication, and PEEP’s role is primarily mechanical, not anti-fibrotic.

C. Apply positive pressure during inhalation to fully inflate the lungs: Positive pressure during inhalation is provided by the tidal volume or inspiratory pressure, not PEEP. PEEP maintains pressure at the end of exhalation, not during inspiration.

D. Prevent alveolar collapse during expiration: PEEP maintains a baseline positive pressure in the lungs at the end of expiration, preventing alveolar collapse (atelectasis). This improves oxygenation, increases functional residual capacity, and reduces ventilator-induced lung injury in ARDS patients.

Correct Answer is {"dropdown-group-1":"C","dropdown-group-2":"B"}

Explanation

Rationale for Correct Answers:

Supraventricular tachycardia: The telemetry strip shows a rapid, regular rhythm originating above the ventricles, consistent with supraventricular tachycardia (SVT), and the heart rate is above 150 beats per minute. SVT can cause palpitations, dizziness, or hypotension if sustained, making accurate identification critical for timely intervention.

Administering adenosine: Adenosine is the first-line pharmacologic treatment for stable SVT. It transiently blocks AV nodal conduction, which can terminate the reentrant tachycardia and restore normal sinus rhythm. Administration requires rapid IV push with immediate saline flush and continuous monitoring due to potential transient bradycardia or brief asystole.

Rationale for Incorrect Answers

Atrial fibrillation: This rhythm is irregularly irregular with no identifiable P waves. SVT is regular and very rapid.

Sinus tachycardia: This has a normal P wave before every QRS complex and is typically caused by pain, fever, dehydration, or anxiety. It is not treated with adenosine.

Defibrillation: This is used for life-threatening rhythms such as ventricular fibrillation or pulseless ventricular tachycardia, not stable SVT.

Administering diltiazem: This is commonly used to control ventricular rate in atrial fibrillation, not as first-line treatment for SVT.

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A patient with massive trauma and possible spinal cord injury is admitted to the emergency department. The nurse suspects that the patient may be experiencing neurogenic shock based on which assessment finding?

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Naxlex Comprehensive Predictor Exams

The nurse anticipates that positive-end-expiratory-pressure (PEEP) will be utilized when a patient with acute respiratory distress syndrome (ARDS) is placed on mechanical ventilation for which purpose?

Correct Answer is D

Explanation

Based on the information in the electronic health record, complete the following sentences using the drop-down lists. The nurse reads the telemetry strip and interprets the client's cardiac rhythm asdropdown. Based on the cardiac rhythm and client assessment, the nurse anticipatesdropdown

Correct Answer is {"dropdown-group-1":"C","dropdown-group-2":"B"}

Explanation

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