An adult with head and facial injuries from a motor vehicle collision is fully immobilized and has a Glasgow coma score of 6. The client is intubated, sedated, and is being prepared for transfer to a regional trauma center. Which intervention(s) should the nurse implement? Select all that apply.

Allow the family to touch and talk to the client.

Reassess the client's vascular access.

Assess neurological vital signs every 15 minutes.

Administer ophthalmic ointment.

Apply soft bilateral wrist restraints for transport.

Answer and Explanation

Correct Answer : A,B,C,D

A. Allow the family to touch and talk to the client. Family presence can provide emotional support for both the client and loved ones. Even though the client is sedated and has a low GCS, familiar voices and touch may reduce stress and anxiety. Allowing family interaction fosters comfort and connection during a critical time.
B. Reassess the client's vascular access. Maintaining secure and functional vascular access is essential for administering fluids, medications, and emergency interventions. Before transport, the nurse should confirm IV patency, ensure secure connections, and assess for signs of infiltration or malfunction. Trauma patients may require additional or larger bore IV access for fluid resuscitation or transfusion.
C. Assess neurological vital signs every 15 minutes. Frequent neurological assessments are crucial in head trauma patients with a low GCS to monitor for signs of worsening intracranial pressure, cerebral edema, or herniation. Changes in pupil response, motor function, or vital signs may indicate neurological deterioration requiring urgent intervention. Monitoring trends over time is necessary for early detection of complications.
D. Administer ophthalmic ointment. Clients with a low GCS often have impaired blinking, placing them at risk for corneal abrasions and dryness. Applying ophthalmic lubricant or artificial tears protects the cornea from injury and promotes eye health. Preventing exposure keratitis is essential in unconscious or sedated clients to avoid long-term ocular damage.
E. Apply soft bilateral wrist restraints for transport. Restraints are unnecessary because the client is sedated, intubated, and has a GCS of 6, meaning they cannot attempt self-extubation or interfere with care. Restraints should only be used if the client demonstrates a risk of harm. Standard transport protocols prioritize sedation and safety measures over restraints unless specifically required.

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Correct Answer is []

Explanation

Answer:

Potential Condition:

Acute Adrenal Crisis

The client has a history of Addison’s disease (chronic steroid use) and recent illness with vomiting, leading to decreased oral intake and medication noncompliance.
Symptoms such as hypotension (80/50 mmHg), tachycardia (115 bpm), confusion, nausea, vomiting, and abdominal pain are classic signs of acute adrenal insufficiency.

Actions to Take:

Bolus Intravenous Fluids

Fluid resuscitation with 0.9% normal saline is critical to restore intravascular volume and correct hypotension due to adrenal insufficiency.

Check Blood Glucose

Hypoglycemia is a common complication of adrenal crisis due to cortisol deficiency, requiring close monitoring and possible glucose administration.

Parameters to Monitor:

Blood Pressure

Hypotension is a hallmark of adrenal crisis and must be monitored closely to assess response to fluid resuscitation and steroid therapy.

Electrolytes

Clients with adrenal crisis often have hyponatremia and hyperkalemia due to aldosterone deficiency, requiring frequent electrolyte monitoring.

Incorrect Choices:

Potential Conditions:

Ketoacidosis: More common in diabetes, presents with high blood glucose and ketonuria.
Diabetes Insipidus: Causes polyuria and dehydration but lacks hypotension and hyperkalemia.
Myxedema: Linked to hypothyroidism, causing bradycardia and hypothermia, not hypotension and hyperkalemia.

Actions to Take:

Hold hydrocortisone dose: Steroid replacement is necessary, not withholding it.
Collect urine for a urinalysis: Not a priority; adrenal crisis is diagnosed via history, symptoms, and labs.
Change intravenous fluids to 0.45%: Hypotension requires 0.9% normal saline, not hypotonic fluids.

Parameters to Monitor:

Urine output: Useful but less critical than blood pressure and electrolytes in adrenal crisis.
Thyroid stimulating hormone: Relevant for hypothyroidism, not adrenal insufficiency.
Heart rate: Tachycardia is expected but is not the most critical indicator of improvement.

A. Apply a high-flow oxygen by face mask. B. Obtain a chest tube insertion kit. C. Withhold narcotic pain medication. D. Elevate the head of the bed 45 degrees. E. Place client in Trendelenburg position.

Correct Answer is A

Explanation

A. Apply high-flow oxygen by face mask. The client is in respiratory distress with absent breath sounds over the left lung field, which is highly suggestive of a pneumothorax or hemothorax. High-flow oxygen helps improve oxygenation while preparing for definitive intervention. In cases of tension pneumothorax, oxygen can help reduce hypoxia until a chest tube or needle decompression is performed.
B. Obtain a chest tube insertion kit. Absent breath sounds on one side following chest trauma strongly suggest a pneumothorax or hemothorax, requiring immediate chest tube placement to re-expand the lung and restore normal ventilation. The nurse should ensure that the equipment for thoracostomy (chest tube insertion) is readily available for the healthcare provider.
C. Withhold narcotic pain medication. Pain control is important in trauma patients, as uncontrolled pain can lead to shallow breathing, atelectasis, and respiratory complications. Narcotics should be used cautiously in clients with respiratory distress, but they are not contraindicated if given at appropriate doses with close monitoring.
D. Elevate the head of the bed 45 degrees. Clients with respiratory distress should be positioned with the head of the bed elevated to improve lung expansion. However, in a suspected pneumothorax, the priority is oxygenation and chest tube insertion. If there is hemodynamic instability, the client may require a flat or semi-Fowler’s position instead.
E. Place client in Trendelenburg position. The Trendelenburg position (head down, feet up) is not appropriate in chest trauma patients. This position can increase intra-abdominal pressure, worsen breathing difficulty, and impair lung expansion. It is typically avoided in clients with respiratory distress or suspected pneumothorax.

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An adult with head and facial injuries from a motor vehicle collision is fully immobilized and has a Glasgow coma score of 6. The client is intubated, sedated, and is being prepared for transfer to a regional trauma center. Which intervention(s) should the nurse implement? Select all that apply.

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Naxlex Comprehensive Predictor Exams

Correct Answer is []

Explanation

Correct Answer is A

Explanation

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