The nurse is caring for an 18-year-old athlete with a possible cervical spine (C-5) injury following a diving accident. The nurse assesses a blood pressure of 70/50 mm Hg, heart rate 45 beats/min, and respirations 26/min. The patient's skin is warm and flushed.
What is the best interpretation of these findings by the nurse?

The patient is experiencing compensated hypovolemic shock.

The patient is experiencing an allergic reaction.

The patient is developing neurogenic shock.

The patient most likely has an elevated temperature.

Answer and Explanation

The Correct Answer is C

Choice A rationale

Compensated hypovolemic shock typically presents with tachycardia as the heart attempts to maintain cardiac output in the face of low volume. Furthermore, the skin is usually cool, pale, and clammy due to peripheral vasoconstriction. In this scenario, the patient is bradycardic with a heart rate of 45 beats/min and has warm, flushed skin, which directly contradicts the clinical presentation of hypovolemia where systemic vascular resistance would be elevated.

Choice B rationale

An allergic reaction or anaphylactic shock involves a massive release of histamine, leading to vasodilation and hypotension. While it can cause flushed skin, it is almost universally accompanied by tachycardia as the body compensates for the drop in blood pressure. The presence of significant bradycardia following a high cervical spine injury strongly points toward a neurological cause rather than an immunological trigger or a hypersensitivity response to an external allergen.

Choice C rationale

A cervical spine injury at C-5 can cause neurogenic shock by interrupting the sympathetic nervous system pathways. This results in loss of vasomotor tone, causing massive vasodilation and warm, flushed skin. Crucially, the loss of sympathetic input to the heart prevents tachycardia, leading to bradycardia despite hypotension. Normal heart rates range from 60 to 100 beats/min, and blood pressure should be around 120÷80 mm Hg, making these findings classic for neurogenic shock.

Choice D rationale

While warm skin can sometimes indicate a fever, the combination of profound hypotension and bradycardia in the context of a diving accident and potential spinal cord injury is pathognomonic for a circulatory collapse of neural origin. An elevated temperature alone would typically cause a compensatory increase in heart rate to meet the metabolic demands of the body. The primary concern here is the hemodynamic instability resulting from the spinal trauma.

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Correct Answer is B

Explanation

Choice B rationale

Many individuals with chronic hepatitis, particularly Hepatitis C, remain asymptomatic for years or even decades. Because the liver has a large functional reserve, significant damage can occur before the patient feels ill. Intravenous drug users are at high risk due to needle sharing, yet they often do not seek testing until end-stage symptoms appear. This lack of awareness contributes to the silent spread of the virus and delays the initiation of necessary antiviral therapies.

Choice A rationale

In the early or acute stages of hepatitis, the liver typically becomes enlarged and tender, a condition known as hepatomegaly. This occurs due to the inflammatory response triggered by the viral infection, leading to cellular swelling and infiltration by immune cells. A normal-sized liver is not a typical finding in active hepatitis. As the disease progresses to advanced cirrhosis, the liver may eventually shrink and become fibrotic, but during the initial presentation, enlargement is the standard.

Choice C rationale

Scleral icterus, or the yellowing of the white part of the eyes, is a common sign of liver dysfunction, but it is usually not the first symptom to appear. The pre-icteric phase of hepatitis often involves non-specific systemic symptoms such as extreme fatigue, low-grade fever, myalgia, and anorexia. Jaundice only develops once bilirubin levels in the blood exceed the normal range of 0.3 to 1.2 mg/dL, which typically happens days or weeks after the initial prodromal symptoms begin.

Choice D rationale

While nausea and vomiting are frequently associated with hepatitis, they are most common during the prodromal or pre-icteric phase rather than the full-blown icteric phase. During the peak of the illness, the primary features are jaundice, dark tea-colored urine, and clay-colored stools due to impaired bilirubin metabolism. Nausea is a general symptom of systemic inflammation and is not considered a specific classic sign of the later stages of the disease compared to jaundice.

A. Decontamination. B. Universal precautions. C. Triaging. D. Defusing.

Correct Answer is A

Explanation

Choice A rationale

Decontamination is the priority step for preventing secondary exposure to chemical agents following a terrorist attack. This process involves the physical removal of the hazardous substance from the patient's skin and clothing, typically using water or specialized solutions. By removing the contaminant immediately, healthcare providers prevent the chemical from continuing to be absorbed by the patient and, crucially, prevent the transfer of the toxin to medical staff and other patients within the treatment facility environment.

Choice B rationale

Universal precautions, now often called standard precautions, are designed to prevent the transmission of bloodborne pathogens like HIV or Hepatitis B in a clinical setting. While they involve the use of personal protective equipment, they are not sufficient to manage chemical contaminants. Chemicals require specific hazardous material protocols and specialized filtration masks or suits. Relying solely on standard precautions without performing thorough decontamination would lead to widespread contamination of the emergency department and the surrounding healthcare environment.

Choice C rationale

Triaging is the process of prioritizing patients based on the severity of their injuries to maximize the number of survivors in a mass casualty event. While triaging is essential for overall scene management, it does not directly address the risk of secondary chemical exposure. If triage is performed before decontamination, the triage officers themselves could become victims of the chemical agent through contact with the contaminated victims, thereby reducing the available medical workforce and complicating the rescue.

Choice D rationale

Defusing is a psychological intervention used to support first responders and victims immediately following a traumatic event to reduce acute stress. While it is a vital part of the recovery phase to prevent long-term post-traumatic stress disorder, it has no biological or physical effect on chemical exposure. The physical threat of the chemical agent must be neutralized through decontamination before any psychological debriefing or defusing can safely take place for the affected population or the responders.

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Naxlex Comprehensive Predictor Exams

Correct Answer is B

Explanation

To decrease the risk of secondary exposure to a chemical that was used in a terrorist attack, which of the following initial steps must be implemented?

Correct Answer is A

Explanation

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