A nurse is caring for a client who has sustained a severe head trauma and has significant bleeding from the nose. Which of the following actions should the nurse take first?
Establish a patent airway
Prepare for a CT scan
Insert a peripheral IV line
Apply direct pressure to the nose.
The Correct Answer is A
Rationale:
A. Establish a patent airway: Severe head trauma with active nasal bleeding raises concern for airway obstruction from blood pooling, impaired consciousness, or loss of protective reflexes. Ensuring a patent airway prevents hypoxia, which can rapidly worsen neurologic injury. Early airway control is the priority because compromised breathing poses an immediate threat to life
B. Prepare for a CT scan: A CT scan is essential for diagnosing intracranial injuries, fractures, and sources of bleeding, but the client must first have a stable airway and adequate oxygenation. Imaging cannot safely proceed until airway patency is confirmed, since deterioration during transport is a major risk.
C. Insert a peripheral IV line: IV access is necessary for fluid resuscitation and medication administration, but it is not the most urgent action when airway compromise is suspected. The risk of hypoxia outweighs the risk of delayed IV access, and airway management must occur before secondary stabilization steps. Once the airway is secured, IV access can be safely done.
D. Apply direct pressure to the nose: Direct pressure is generally used to control epistaxis, but in severe head trauma, nasal bleeding may indicate a basilar skull fracture, and pressure could worsen underlying injury or dislodge clots. Additionally, controlling bleeding is secondary to securing the airway, as blood flow can interfere with breathing.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
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Explanation
Rationale for correct choices
• Osteoarthritis: The client presents with chronic, localized joint pain in the right knee and left wrist, along with crepitus and no systemic symptoms. Laboratory results show normal ESR and negative ANA, making inflammatory or autoimmune conditions unlikely. Osteoarthritis is a degenerative joint disease characterized by gradual cartilage breakdown, joint stiffness, and crepitus, consistent with this client’s findings.
• Instruct the client to apply heat and cold: Alternating heat and cold therapy helps reduce joint stiffness, improve circulation, and relieve pain in osteoarthritis. Heat can relax muscles and increase flexibility before activity, while cold can reduce inflammation and swelling after activity. Teaching the client proper application can improve comfort and functional mobility.
• Instruct the client to apply topical analgesics: Topical analgesics, such as NSAID gels or menthol-based creams, can provide localized pain relief without systemic side effects. This approach is particularly useful for clients with osteoarthritis who have isolated joint pain. Incorporating topical treatments into daily self-care can enhance quality of life and support mobility.
• Joint deformities: Monitoring joint deformities over time helps assess the progression of osteoarthritis. Osteophyte formation, malalignment, or decreased joint space can indicate worsening disease. Regular assessment allows early intervention to preserve function and prevent disability.
• ESR: Although ESR is normal in early osteoarthritis, monitoring it can help distinguish between degenerative and inflammatory processes if new symptoms arise. Tracking ESR ensures any unexpected systemic inflammation is promptly investigated, supporting accurate diagnosis and management.
Rationale for incorrect choices
• Gout: Gout typically presents with sudden, severe pain, redness, and swelling in a single joint, often the first metatarsophalangeal joint. The client’s chronic, gradual joint pain with crepitus and normal uric acid levels is not consistent with an acute gout flare, making this diagnosis unlikely.
• Systemic lupus erythematosus (SLE): SLE usually presents with multi-system involvement, positive ANA, rashes, and systemic inflammation. The client has negative ANA, no rashes, and localized joint pain, which rules out SLE as the primary condition.
• Rheumatoid arthritis (RA): RA is an autoimmune disease characterized by symmetrical joint involvement, morning stiffness lasting over an hour, and elevated inflammatory markers such as ESR. The client’s isolated joint involvement, absence of morning stiffness, and normal labs make RA unlikely.
• Instruct the client to avoid foods high in purines: Dietary purine restriction is relevant for gout, not osteoarthritis. Since the client does not exhibit acute gout symptoms and uric acid is within normal range, this action is unnecessary.
• Instruct the client to use mild soaps for cleansing skin: Skin care with mild soaps is a teaching point for autoimmune or dermatologic conditions, not osteoarthritis. It does not address joint pain, stiffness, or mobility, making it irrelevant in this case.
• Instruct the client to avoid live vaccines: Avoiding live vaccines is a precaution for immunosuppressed clients, such as those on immunosuppressants for RA or SLE. The client has osteoarthritis and is not immunocompromised, so this action is not indicated.
• Uric acid level: While uric acid is relevant for gout monitoring, the client’s uric acid is within normal range and osteoarthritis does not cause hyperuricemia. Therefore, this parameter is not necessary for monitoring in this case.
• Lymphadenopathy: Lymphadenopathy is associated with systemic infections or autoimmune conditions. The client does not show systemic involvement, so lymph node monitoring is not relevant.
• ANA: ANA testing is primarily used to screen for autoimmune disorders such as SLE. The client already has a negative ANA and does not present systemic symptoms, so repeating ANA is unnecessary.
Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"A","dropdown-group-3":"A","dropdown-group-4":"A"}
Explanation
Rationale for correct choices
• Blurred vision: Amitriptyline is a tricyclic antidepressant that has anticholinergic effects, which can reduce the ability of the eyes to focus and cause blurred vision. Clients should be warned about potential difficulty with reading or driving until they know how the medication affects their vision. This adverse effect is common and may persist throughout therapy.
• Orthostatic hypotension Amitriptyline can block alpha-adrenergic receptors, leading to vasodilation and a drop in blood pressure upon standing. Clients may experience dizziness, lightheadedness, or fainting, especially when moving from sitting to standing. Monitoring blood pressure and educating the client to rise slowly are important preventive strategies.
• Urinary retention Anticholinergic effects of amitriptyline can impair bladder contraction, causing difficulty initiating urination or incomplete emptying. This is particularly important in older adults or clients with preexisting urinary issues. Teaching clients to report urinary hesitancy or discomfort helps prevent complications such as infection.
• Constipation Amitriptyline slows gastrointestinal motility due to its anticholinergic properties, making constipation a common adverse effect. Clients may need dietary adjustments, increased fluid intake, or stool softeners. Early teaching on prevention is important to reduce discomfort and maintain regular bowel habits.
Rationale for incorrect choices
• Tinnitus: Tinnitus is not commonly associated with amitriptyline therapy. While some medications can cause ringing in the ears, this is not a primary concern with tricyclic antidepressants. It is less likely to be observed or require teaching.
• Sore throat: Sore throat is not a known adverse effect of amitriptyline. Upper respiratory symptoms are unrelated to the anticholinergic and adrenergic effects of this medication, making this an inappropriate teaching point.
• Bradycardia: Amitriptyline does not typically cause bradycardia; it may instead affect conduction and potentially lead to arrhythmias in susceptible clients, but slowing the heart rate is uncommon. Monitoring focuses on blood pressure rather than heart rate reduction.
• Peripheral edema: Peripheral edema is not a common effect of amitriptyline. Fluid retention is not typically induced by tricyclic antidepressants, so this is not a relevant teaching point.
• Increased urination: Amitriptyline generally causes urinary retention rather than increased urination due to anticholinergic effects. Increased urination is not expected and is not a priority to include in client teaching.
• Dysuria: While urinary retention can cause discomfort, dysuria (painful urination) is not a direct effect of amitriptyline. Any urinary pain would likely be secondary to infection, not the medication itself.
• Diarrhea: Amitriptyline slows gastrointestinal motility, so diarrhea is not a common effect. Constipation is far more likely due to anticholinergic activity.
• Nausea with vomiting: Although some clients may experience mild nausea initially, constipation is more directly linked to the anticholinergic mechanism and is more consistent as a common teaching point. Nausea is less frequent and usually transient.
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