The ICU nurse receives report on a new client being admitted with a neck injury he received while diving into a lake. The ED nurse reports that his temp is 98.2, blood pressure is 85/54, heart rate is 53 beats per minute, and his skin is warm and dry. What does the ICU nurse recognize that that client is probably experiencing?

Neurogenic shock

Anaphylactic shock

Septic shock

Hypovolemic shock

Answer and Explanation

The Correct Answer is A

A. Neurogenic shock is correct because it occurs following a spinal cord injury, especially above T6, leading to loss of sympathetic nervous system tone. This results in hypotension, bradycardia, and warm, dry skin due to unopposed parasympathetic activity and peripheral vasodilation. The combination of low blood pressure, low heart rate, and warm skin is classic for neurogenic shock, distinguishing it from other types of shock.

B. Anaphylactic shock is incorrect because it usually presents with hypotension, tachycardia, and warm, flushed skin, often accompanied by urticaria, airway swelling, and respiratory distress, which are not described in this client.

C. Septic shock is incorrect because septic shock typically presents with hypotension, tachycardia, fever or hypothermia, and warm, flushed skin in the early stages. This client’s heart rate is bradycardic, not tachycardic, and he has a normal temperature, making sepsis less likely.

D. Hypovolemic shock is incorrect because it usually presents with hypotension, tachycardia, and cool, clammy skin due to decreased circulating volume and sympathetic compensatory mechanisms. This client’s skin is warm and dry, which is inconsistent with hypovolemic shock.

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Correct Answer is D

Explanation

A. That there is a high potential for acute respiratory distress syndromeis incorrect because although ARDS can occur after severe trauma, it is not the immediate guiding principle during initial emergency assessment. The primary focus is stabilization and prevention of further injury.

B. That the risk of survival is likely very lowis incorrect because assumptions about survival do not guide safe clinical care. Trauma management is focused on systematic assessment and rapid intervention to improve survival outcomes.

C. That there is likely for multiple bone fracturesis incorrect because while fractures are common in motor vehicle collisions, they are not the highest priority concern during initial assessment. Airway, breathing, circulation, and spinal protection take precedence.

D. That a spinal cord injury exists until proven otherwiseis correct because in any client involved in significant trauma, especially a motor vehicle collision, spinal injury must be assumed. Maintaining spinal immobilization and preventing neck movement are critical to avoid further neurological damage. This principle aligns with trauma protocols emphasizing spinal precautions during primary survey assessment.

A. Amyloidosis B. Pneumothorax C. Pulmonary edema D. Opioid analgesic overdose

Correct Answer is D

Explanation

A. Amyloidosiscan affect the lungs or heart and may contribute to respiratory failure, but this is generally considered a pulmonary or systemic diseasecausing intrapulmonary problems rather than an extrapulmonary cause of ventilatory failure.

B. Pneumothoraxis a pulmonary causeof respiratory failure. It directly impairs lung expansion and gas exchange by causing air to accumulate in the pleural space.

C. Pulmonary edemais another pulmonary causeof respiratory failure. It occurs due to fluid accumulation in the alveoli, impairing oxygenation and ventilation.

D. Opioid analgesic overdoseis an extrapulmonary cause of ventilatory failure. Opioids depress the central nervous system, particularly the medullary respiratory centers, leading to hypoventilation, decreased tidal volume, and elevated arterial CO₂ (hypercapnia). This is a classic example of ventilatory failure caused by a neurologic or pharmacologic extrapulmonary issue, rather than intrinsic lung disease.

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Naxlex Comprehensive Predictor Exams

The nurse is admitting a client to the emergency department (ED) who was in a motor vehicle collision and has multiple traumatic injuries. Which of the following assumptions is a priority guiding principle for the nurse in this situation?

Correct Answer is D

Explanation

A client in acute respiratory failure is classified as having ventilatory failure. The nurse understands that which finding is a potential extrapulmonary cause of ventilatory failure?

Correct Answer is D

Explanation

Following management of a disaster, a patient care technician tells the nurse, "I keep seeing the faces of people that died when I close my eyes." What is the appropriate nursing response?

The nurse is assessing a client who is in shock. Which of the following findings would indicate to the nurse that the client is entering an irreversible stage?

The nurse is providing care for a patient who was assaulted with a baseball bat resulting in physical trauma to the abdomen. Which type of injury does the patient have?

Which statement describes the concept of scene safety in trauma situations?

The nurse is caring for a female client who has been seen at the ED multiple times recently for sexually transmitted infections and various physical concerns. When the client's boyfriend goes for coffee, what is the priority nursing action?

Which one of the following assessments is most appropriate for determining the correct placement of an endotracheal tube in a mechanically ventilated client?

The nurse is caring for a client with rib fractures and a pneumothorax who reports a pain score of 8/10. The nurse administered prescribed hydromorphone IV push and reassesses the client in 30 minutes. What data indicates that the treatment is effective?