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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

Answer and Explanation

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.

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Correct Answer is B

Explanation

A. Control dysrhythmias and decrease the heart rate

Controlling dysrhythmias is important, but decreasing heart rate is not always the goal, as a compensatory tachycardia may be necessary for perfusion.

B. Decrease cardiac workload and increase systemic perfusion

Cardiogenic shock results from impaired cardiac output. The goal is to reduce the heart’s workload (e.g., by reducing afterload) while improving systemic perfusion.

C. Improve oxygen exchange and decrease urinary output

Oxygenation is important, but decreased urinary output indicates poor renal perfusion and worsening shock, which is not a goal of treatment.

D. Decrease the blood pressure and respiratory rate

In cardiogenic shock, blood pressure is already low. The goal is to maintain adequate perfusion, not to further reduce BP.

A. Bend the client's head toward their chest B. Ask the client to extend both arms above their head C. Place the client in supine position D. The nurse will place a hand behind the client's head E. Assist the client to bend their knee 90 degrees

Correct Answer is ["A","C","D"]

Explanation

A. Bend the client’s head toward their chest is correct because Brudzinski’s sign is tested by flexing the client’s neck and observing for an involuntary flexion of the hips and knees, which suggests meningeal irritation.

B. Ask the client to extend both arms above their head is incorrect; this is not part of the test for Brudzinski’s sign.

C. Place the client in a supine position is correct because the test must be done with the client lying flat on their back.

D. The nurse will place a hand behind the client’s head is correct because the nurse gently lifts the client’s head to assess for involuntary hip and knee flexion.

E. Assist the client to bend their knee 90 degrees is incorrect; knee bending is not required for Brudzinski’s sign but is part of Kernig’s sign testing.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

What is the goal of treatment for the client diagnosed with cardiogenic shock?

Correct Answer is B

Explanation

The nurse is assessing a client for Brudzinskis sign as part of their neurologic assessment. Which of the following are appropriate actions by the nurse when performing this technique? SELECT ALL THAT APPLY

Correct Answer is ["A","C","D"]

Explanation

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