John, a 35-year-old male involved in a motor vehicle accident, presents with a contusion across his chest from the seatbelt. Which two combined assessments should the nurse prioritize to detect potential complications?

Assess for sternal tenderness and check for skin abrasions.

Assess for sternal tenderness and measure oxygen saturation levels.

Measure blood pressure and observe for signs of localized infection

Measure oxygen saturation levels and auscultate lung sounds

Answer and Explanation

The Correct Answer is D

A.   While assessing sternal tenderness is relevant, skin abrasions may not directly indicate complications from the chest contusion.

B.   Sternal tenderness can indicate underlying injuries but is not the priority compared to auscultation of the lung zones, and measuring oxygen saturation levels is crucial for assessing respiratory function and detecting potential complications such as respiratory distress or hypoxemia.
C.   Blood pressure measurement and observation for signs of localized infection are important assessments but may not be directly related to complications from a chest contusion.
D.   This is because a contusion across the chest from the seatbelt can cause rib fractures, pneumothorax, hemothorax, or pulmonary contusion, which can impair gas exchange and oxygenation. Measuring oxygen saturation levels and auscultating lung sounds can help detect these complications and guide appropriate interventions.

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Correct Answer is D

Explanation

A. While position changes are important, maintaining proper head positioning is crucial for managing increased intracranial pressure (ICP).
B. While assessing the patient's level of consciousness is important, excessive stimulation can increase ICP.
C. Keeping the patient flat can exacerbate increased ICP, and elevation of the head is preferred.
D. Elevating the head of the bed helps promote venous drainage from the brain and can reduce ICP.

A. Reflex bronchoconstriction B. Mucociliary clearance system C. Alveolar macrophages D. Chemoreceptors respond to changes in PaCO2 and Ph

Correct Answer is A

Explanation

A. Exposure to strong odors can trigger reflex bronchoconstriction, leading to symptoms like difficulty breathing and chest tightness, especially in individuals with hypersensitive airways.
B. While the mucociliary clearance system plays a role in removing inhaled particles and irritants from the airways, it is not primarily responsible for acute symptoms like difficulty breathing.
C. Alveolar macrophages are involved in phagocytosis and defense against inhaled particles and pathogens but are not directly involved in causing acute respiratory symptoms like bronchoconstriction.
D. Chemoreceptors primarily regulate respiratory drive in response to changes in blood gases and pH but are not directly responsible for bronchoconstriction in response to odor exposure.

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John, a 35-year-old male involved in a motor vehicle accident, presents with a contusion across his chest from the seatbelt. Which two combined assessments should the nurse prioritize to detect potential complications?

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