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 B

Explanation

A. Reflex bronchoconstriction is a defense mechanism that helps protect the airway during exposure to irritants or allergens, but it wouldn't typically lead to irritation and burning sensation.
B. The mucociliary clearance system, which helps remove particles and pathogens from the airway by moving mucus upward via ciliary action, is likely compromised in Emily, leading to accumulation of irritants and subsequent symptoms.
C. Filtration of air occurs primarily in the upper respiratory tract and is not directly related to irritation and burning sensation in the airway.
D. Alveolar macrophages are primarily involved in defense against pathogens in the alveoli of the lungs and are not directly related to irritation and burning sensation in the airway.

A. The body produces new antibodies against the virus. B. The patient will experience systemic symptoms like fever and malaise. C. Sensitized T lymphocytes specifically target and eliminate the invading viral cells. D. Cell-mediated response doesn't kick in until the WBC count rises. E. Eating food

Correct Answer is C

Explanation

A. This describes the humoral immune response, where B lymphocytes produce antibodies against the virus.
B. This describes the systemic effects of inflammation, which can occur in both humoral and cell-mediated responses.
C. This accurately describes the cell-mediated immune response, where T lymphocytes directly target and kill infected cells.
D. The cell-mediated immune response can occur independently of changes in white blood cell (WBC) count.

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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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Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is C

Explanation

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