The nurse is caring for a client who was admitted to the emergency department following a head-on motor vehicle crash. The client is unresponsive, has respirations of 22/min, and a bleeding laceration to the forehead. Which of the following is the priority nursing action at this time?
Establish IV access and start fluid replacement.
Insert nasogastric tube.
Keep neck stabilized.
Monitor pulse and blood pressure frequently.
The Correct Answer is C
Choice A Reason:
Establishing IV access and starting fluid replacement is important for maintaining hemodynamic stability, especially if there is significant blood loss. However, it is not the immediate priority in this scenario. Ensuring the neck is stabilized takes precedence to prevent potential spinal cord injury.
Choice B Reason:
Inserting a nasogastric tube is not a priority in the acute management of a trauma patient with a head injury. This procedure can be deferred until the patient's airway and cervical spine are secured and other life-threatening conditions are addressed.
Choice C Reason:
Keeping the neck stabilized is the priority action. In a trauma patient with a head injury, there is a high risk of cervical spine injury. Stabilizing the neck prevents further damage to the spinal cord, which could result in paralysis or other severe complications.
Choice D Reason:
Monitoring pulse and blood pressure frequently is essential for assessing the patient's hemodynamic status. However, it is not the immediate priority over stabilizing the cervical spine. Once the neck is stabilized, continuous monitoring of vital signs should follow.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A Reason:
Reduced blood pressure is not a specific complication of infective endocarditis. While hypotension can occur in severe cases due to septic shock, it is not a hallmark of the disease. Infective endocarditis primarily affects the heart valves and can lead to embolic events, heart failure, and other complications.
Choice B Reason:
Osler's nodes are a classic sign of infective endocarditis. These are painful, red or purple, raised lesions found on the hands and feet. They are caused by immune complex deposition and are indicative of the systemic nature of the infection. Their presence can help in the clinical diagnosis of infective endocarditis.
Choice C Reason:
Clear lung sounds are not a complication of infective endocarditis. In fact, clear lung sounds would generally indicate that there is no pulmonary involvement or congestion. Complications of infective endocarditis are more likely to involve the heart, kidneys, and other organs through embolic events.
Choice D Reason:
Increased appetite is not associated with infective endocarditis. Patients with this condition often experience symptoms such as fever, fatigue, and weight loss due to the chronic infection. Increased appetite would be an unusual finding and not related to the disease process.
Correct Answer is C
Explanation
Choice A Reason:
Narrowing pulse pressure is not typically associated with contusions from a motor-vehicle crash. It is more commonly seen in conditions like cardiac tamponade or severe blood loss. While it can indicate a serious condition, it is not a direct result of a contusion.
Choice B Reason:
Drainage of clear fluid from the ears, known as otorrhea, can indicate a basilar skull fracture rather than a simple contusion. This finding suggests cerebrospinal fluid leakage, which is a serious complication requiring immediate medical attention.
Choice C Reason:
Periods of unconsciousness and/or confusion are expected findings in clients with contusions, especially if the brain is involved. These symptoms indicate a concussion or more severe brain injury, which can result from the impact of a motor-vehicle crash.
Choice D Reason:
Extensive bruising in the mastoid area, known as Battle's sign, is indicative of a basilar skull fracture rather than a contusion. This type of bruising appears behind the ear and is a sign of a more severe head injury.
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