The nurse in the trauma unit has received a report on a client who has multiple injuries following a motor vehicle crash. Which of the following actions should the nurse plan to take first?
Check pupillary response to light.
Check the client's response to questions about place and time.
Assess the capillary refill.
Evaluate chest expansion.
The Correct Answer is A
Choice A rationale:
(Correct Choice) Checking pupillary response to light is a critical first step in the assessment of a client with multiple injuries following a motor vehicle crash. Pupillary changes can indicate neurological issues, increased intracranial pressure, or damage to the brainstem. Rapidly assessing pupil size, equality, and reactivity helps identify potential life-threatening conditions.
Choice B rationale:
Checking the client's response to questions about place and time is important but not the highest priority in this scenario. Neurological and physiological stability should be addressed first to ensure the client's overall well-being.
Choice C rationale:
Assessing capillary refill is valuable in assessing peripheral circulation and hydration status. However, it is not the primary concern when dealing with a client who has potentially sustained traumatic injuries, where neurological and intracranial issues need to be ruled out or addressed urgently.
Choice D rationale:
Evaluating chest expansion is relevant for assessing lung function and detecting potential injuries like rib fractures. However, given the context of a trauma client, focusing on neurological assessment takes precedence over respiratory assessment in the immediate term.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Volunteer to provide an inservice about infection control.While providing an inservice about infection control is important, it is not the immediate priority. The nurse needs to address the current situation to prevent potential contamination and infection spread.
B. Speak with the AP when he exits the room about the appropriate protocol.Speaking with the AP about the appropriate protocol is necessary, but it should be done after ensuring the immediate safety of the client and others. Delaying action could result in exposure to infectious agents.
C. Provide the appropriate PPE to the AP.This action addresses the immediate risk of infection transmission. By providing the appropriate PPE, the nurse ensures that the AP can safely continue their duties without putting themselves or the client at risk.
D. Notify the charge nurse about the AP's need for training.Notifying the charge nurse is important for long-term improvement, but it does not address the immediate risk. The nurse must first ensure that the AP is properly equipped to handle the current situation safely.
Correct Answer is D
Explanation
Choice A rationale:
The choice "Pigeon" is not the correct answer. Pigeon chest, also known as pectus carinatum, is a deformity of the chest characterized by a protrusion of the sternum and ribs. This condition is not associated with chronic bronchitis.
Choice B rationale:
The choice "Funnel" is not the correct answer. Funnel chest, or pectus excavatum, is a deformity where the sternum is sunken into the chest. It is not the expected chest shape in chronic bronchitis.
Choice C rationale:
The choice "Kyphotic" is not the correct answer. Kyphosis refers to an excessive outward curvature of the thoracic spine, leading to a rounded upper back appearance. This is not the typical chest shape seen in chronic bronchitis.
Choice D rationale:
The correct answer is "Barrel." Choice D is the correct answer. Chronic bronchitis is a type of chronic obstructive pulmonary disease (COPD) characterized by airway inflammation and narrowing. Over time, this can lead to air trapping in the lungs and an increase in the anteroposterior diameter of the chest. This results in a barrel-shaped chest appearance, where the chest appears rounded and the ribs are more horizontal. This adaptation allows for increased lung capacity to accommodate for the compromised airflow in patients with chronic bronchitis.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.