The nurse is caring for a patient who was in a motor vehicle accident that resulted in cervical trauma to C4. Which assessment is the priority?
Respirations
Pulse
Temperature
Blood Pressure
The Correct Answer is A
A. Respirations: C4 injuries compromise the phrenic nerve, which controls the diaphragm. A high cervical spine injury can lead to respiratory failure, making airway and breathing the top priority.
B. Pulse: While monitoring circulation is important, breathing takes priority in a C4 injury due to the risk of respiratory paralysis.
C. Temperature: Temperature regulation may be affected due to autonomic dysfunction, but airway and breathing remain the priority.
D. Blood Pressure: While spinal cord injuries can cause neurogenic shock (low BP, bradycardia), ensuring airway and breathing comes first.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Pleural effusion: A pleural effusion is the accumulation of fluid in the pleural space and is not directly related to atelectasis. Atelectasis is alveolar collapse and does not cause fluid buildup.
B. Hypoxemia: Atelectasis impairs gas exchange, leading to decreased oxygen levels (hypoxemia) due to collapsed alveoli. This is a hallmark finding.
C. Dysphagia: Dysphagia (difficulty swallowing) is not a direct symptom of atelectasis. It may be seen in stroke or esophageal disorders.
D. Apnea: Apnea (cessation of breathing) is not a typical sign of atelectasis. Atelectasis causes shallow breathing, dyspnea, and hypoxia rather than complete cessation.
Correct Answer is D
Explanation
A. Aortic and Mitral: The mitral valve is associated with the S1 sound, not S2. S2 occurs when the semilunar valves (aortic and pulmonic) close.
B. Mitral and Pulmonic: The mitral valve closure is heard in S1, while the pulmonic valve closure is part of S2. However, the mitral valve is not involved in S2.
C. Mitral and Tricuspid: The mitral and tricuspid valves close during S1, not S2. These valves are atrioventricular (AV) valves, not semilunar valves.
D. Aortic and Pulmonic: The second heart sound (S2) is produced by the closure of the aortic and pulmonic valves at the beginning of diastole. This marks the end of systole.
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.