A nurse in an emergency department is preparing to care for a client who is being brought in with multiple system trauma following a motor vehicle crash. Which of the following should the nurse identify as the priority focus of care?

Preventing musculoskeletal disability

Airway protection

Stabilizing cardiac arrhythmias

Decreasing intracranial pressure

Answer and Explanation

The Correct Answer is B

Choice A Reason: Preventing musculoskeletal disability is important, but not the priority focus of care. The nurse should first assess and manage the client's life-threatening injuries, such as airway obstruction, bleeding, shock, or brain injury.

Choice B Reason: Airway protection is the priority focus of care for a client with multiple system trauma. The nurse should ensure that the client has a patent airway and adequate ventilation, as any compromise in these areas can quickly lead to hypoxia, respiratory failure, and death.

Choice C Reason: Stabilizing cardiac arrhythmias is also important, but not the priority focus of care. The nurse should monitor the client's cardiac rhythm and treat any arrhythmias that may occur, but only after securing the airway and breathing.

Choice D Reason: Decreasing intracranial pressure is another important goal, but not the priority focus of care. The nurse should assess the client's neurological status and intervene to prevent or reduce increased intracranial pressure, such as elevating the head of the bed, maintaining normothermia, and administering osmotic diuretics. However, these measures are secondary to ensuring adequate oxygenation and perfusion.

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Correct Answer is B

Explanation

Choice A Reason: This is incorrect because the client is not in deep coma, as the Glasgow Coma Scale (GCS) score ranges from 3 to 15, with 3 being the lowest possible score and indicating deep coma or death.

Choice B Reason: This is correct because the client needs total nursing care, as the GCS score of 6 indicates a severe brain injury and a very low level of consciousness. The client may only open his eyes to pain, make incomprehensible sounds, and have abnormal ﬂexion to pain.

Choice C Reason: This is incorrect because the client is not alert and oriented, as the GCS score of 6 indicates a severe brain injury and a very low level of consciousness. The client may not be able to follow commands, answer questions, or recognize people or places.

Choice D Reason: This is incorrect because the client is not responding to verbal stimuli, as the GCS score of 6 indicates a severe brain injury and a very low level of consciousness. The client may only respond to painful stimuli, such as pinching or squeezing.

A. The laboratory values are within the expected reference range. B. The laboratory values are prolonged. C. The laboratory values are the same as the previous test values. D. The laboratory values are decreased.

Correct Answer is B

Explanation

Choice A Reason: This is incorrect because the laboratory values are not within the expected reference range in a client who has DIC. DIC is a condition that causes abnormal activation of the clotting cascade, leading to widespread microthrombi formation and consumption of clotting factors and platelets. This results in bleeding complications and organ dysfunction.

Choice B Reason: This is correct because the laboratory values are prolonged in a client who has DIC. PT, aPTT, and INR are tests that measure the time it takes for blood to clot. PT measures the extrinsic pathway, aPTT measures the intrinsic pathway, and INR is a standardized ratio of PT. In DIC, these tests are prolonged because of the depletion of clotting factors and platelets.

Choice C Reason: This is incorrect because the laboratory values are not the same as the previous test values in a client who has DIC. DIC is an acute and dynamic condition that can change rapidly depending on the underlying cause and treatment. The laboratory values may ﬂuctuate between normal, prolonged, or shortened depending on the balance between clotting and bleeding.

Choice D Reason: This is incorrect because the laboratory values are not decreased in a client who has DIC. Decreased laboratory values would indicate a shortened clotting time, which can occur in some cases of DIC when there is excessive clotting and thrombosis. However, this is not the typical finding in DIC, as most clients present with bleeding manifestations and prolonged clotting time.

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A nurse in an emergency department is preparing to care for a client who is being brought in with multiple system trauma following a motor vehicle crash. Which of the following should the nurse identify as the priority focus of care?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is B

Explanation

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