A nurse in an emergency department is assisting with the care of a client who is unconscious and has trauma to multiple systems following a motor vehicle crash. Which of the following actions should the nurse take first?
Airway protection
Stabilizing cardiac arrhythmias
Preventing musculoskeletal disability
Decreasing intracranial pressure
The Correct Answer is A
Choice A reason: This action is correct because airway protection is the first priority for a client who is unconscious and has trauma to multiple systems. The nurse should assess the client's airway patency, breathing, and oxygenation, and intervene as needed to secure and maintain the airway. The nurse should also monitor the client for signs of aspiration, bleeding, or obstruction, and suction the airway as needed.
Choice B reason: This action is incorrect because stabilizing cardiac arrhythmias is not the first priority for a client who is unconscious and has trauma to multiple systems. The nurse should assess the client's circulation, blood pressure, and pulse, and intervene as needed to treat any arrhythmias, shock, or hemorrhage. However, this is not a priority over the client's airway, which is essential for survival.
Choice C reason: This action is incorrect because preventing musculoskeletal disability is not the first priority for a client who is unconscious and has trauma to multiple systems. The nurse should assess the client's mobility, sensation, and alignment, and intervene as needed to prevent or treat any fractures, dislocations, or nerve injuries. However, this is not a priority over the client's airway, which is essential for survival.
Choice D reason: This action is incorrect because decreasing intracranial pressure is not the first priority for a client who is unconscious and has trauma to multiple systems. The nurse should assess the client's level of consciousness, pupillary response, and neurological status, and intervene as needed to prevent or treat any increased intracranial pressure, cerebral edema, or brain injury. However, this is not a priority over the client's airway, which is essential for survival.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: This statement is false and should not be included in the educational session. TJC is not a for profit organization, but rather an independent, not-for-profit organization that accredits and certifies more than 21,000 health care organizations and programs in the United States.
Choice B reason: This statement is false and should not be included in the educational session. TJC is not an organization that monitors insurance claims, but rather an organization that evaluates health care organizations and inspires them to excel in providing safe and effective care of the highest quality and value.
Choice C reason: This statement is false and should not be included in the educational session. TJC does not provide licensure for health care providers, but rather accreditation and certification for health care organizations and programs. Licensure is the process by which a governmental authority grants permission to individuals or entities to engage in a regulated activity or profession.
Choice D reason: This statement is true and should be included in the educational session. TJC provides accreditation to facilities, which is a voluntary process that involves an external review of an organization's compliance with certain standards and criteria. Accreditation is recognized nationwide as a symbol of quality that reflects an organization's commitment to meeting certain performance standards.
Correct Answer is D
Explanation
Choice A reason: Preventing opioid use is not a benefit of de-escalation techniques. Opioid use is a complex issue that involves biological, psychological, and social factors, and cannot be prevented by simply deescalating emotional situations. De-escalation techniques may help to calm or soothe someone who is experiencing pain or distress, but they do not address the underlying causes or consequences of opioid use.
Choice B reason: Increasing communication is not a benefit of de-escalation techniques, but a means or a strategy to achieve de-escalation. Communication is an essential skill that helps to deescalate emotional situations by listening, validating, empathizing, and problem solving with the other person. Communication can also help to prevent or reduce conflicts, misunderstandings, and aggression. However, communication is not an outcome or a result of de-escalation, but a process or a tool to facilitate de-escalation.
Choice C reason: Decreasing hallucinations is not a benefit of de-escalation techniques. Hallucinations are perceptual disturbances that involve seeing, hearing, feeling, smelling, or tasting things that are not there. Hallucinations can be caused by various factors, such as mental disorders, neurological conditions, substance use, or medication side effects. De-escalation techniques may help to manage or cope with hallucinations, but they do not treat or eliminate them.
Choice D reason: Reducing restraint use is a benefit of de-escalation techniques. Restraint use is a practice that involves restricting the movement or behavior of a person who poses a risk of harm to themselves or others. Restraint use can have negative effects on the physical and psychological wellbeing of the person, such as injuries, infections, agitation, and trauma. De-escalation techniques can help to avoid or minimize the need for restraint use by resolving or calming emotional situations in a safe and respectful manner.
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