The nurse is caring for a client who received a blunt force injury to zone II of the neck. Which assessment finding should the nurse report to the physician IMMEDIATELY?
Deep purple erythema
Facial nerve deficits
Dysphonia or dysphagia
Heart rate of 10 and blood pressure of 96/68
The Correct Answer is C
A. Deep purple erythema
This suggests bruising or possible hematoma formation, which is concerning but may not be immediately life-threatening.
B. Facial nerve deficits
This indicates nerve injury, which is serious but may not be immediately life-threatening.
C. Dysphonia or dysphagia
Dysphonia (difficulty speaking) or dysphagia (difficulty swallowing) are signs of airway compromise or injury to structures involved in breathing and swallowing. This requires immediate attention.
D. Heart rate of 100 and blood pressure of 96/68
These vital signs indicate tachycardia and borderline hypotension, which are concerning, but the airway compromise (option C) is more immediately life-threatening.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Deep purple erythema
This suggests bruising or possible hematoma formation, which is concerning but may not be immediately life-threatening.
B. Facial nerve deficits
This indicates nerve injury, which is serious but may not be immediately life-threatening.
C. Dysphonia or dysphagia
Dysphonia (difficulty speaking) or dysphagia (difficulty swallowing) are signs of airway compromise or injury to structures involved in breathing and swallowing. This requires immediate attention.
D. Heart rate of 100 and blood pressure of 96/68
These vital signs indicate tachycardia and borderline hypotension, which are concerning, but the airway compromise (option C) is more immediately life-threatening.
Correct Answer is D
Explanation
A. Decrease chest pain is important but not the highest priority. Managing pain can help with breathing, but oxygenation is the primary concern.
B. Reduce the client's anxiety is secondary to physiological needs. Anxiety can worsen dyspnea, but addressing oxygenation first is more critical.
C. Maintain adequate circulating volume is a priority if there is hemorrhage, but the question does not indicate bleeding. Oxygenation takes precedence in this case.
D. Maintain adequate oxygenation is the priority. Chest trauma can lead to pneumothorax, pulmonary contusion, or other complications that can impair gas exchange. Ensuring adequate oxygenation prevents hypoxia and respiratory failure, which are life-threatening.
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