A nurse is caring for a client who is in the emergency department with multiple traumatic injuries following a motor-vehicle crash. Which of the following actions should the nurse take first?

Establish a patent oral airway.

Remove the client's clothing.

Warm blood products prior to administration.

Assign the client a score on the Glasgow Coma Scale

Answer and Explanation

The Correct Answer is A

Rationale:

A. Establish a patent oral airway: The airway is the highest priority in trauma care, following the ABCs (Airway, Breathing, Circulation). Without a patent airway, the client cannot oxygenate properly, which can quickly become life-threatening.

B. Remove the client's clothing: This helps with full-body assessment and prevention of missed injuries, but it should only be done after ensuring the client’s airway and breathing are stable.

C. Warm blood products prior to administration: While this helps prevent hypothermia during transfusion, warming blood is not the immediate priority in a trauma situation. Circulation support follows airway and breathing in priority.

D. Assign the client a score on the Glasgow Coma Scale: Neurological assessment is important but comes after airway stabilization. The GCS helps evaluate consciousness but should not delay securing the airway in an emergency.

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Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"C"}

Explanation

Rationale for Correct Choices:

Reye's syndrome: The toddler's worsening condition including vomiting, lethargy, and altered consciousness after a viral illness (influenza A) is consistent with Reye’s syndrome, which affects the liver and brain. The progression from mild viral symptoms to neurologic decline without respiratory compromise further supports this diagnosis.
Aspirin administration: Giving aspirin during a viral illness in children is a well-known precipitant of Reye’s syndrome. The caregivers' report of alternating aspirin with acetaminophen confirms the exposure necessary to trigger the condition in a susceptible child.

Rationale for Incorrect Choices:

Gastroenteritis: While vomiting is a feature of gastroenteritis, the absence of diarrhea and the presence of neurologic changes like lethargy and poor responsiveness make this unlikely. Additionally, the clear vomiting and lack of fluid intake without prior GI focus suggest another etiology.
Bronchitis: Bronchitis typically causes a productive cough with wheezing, chest discomfort, and possible fever. This toddler's lungs are clear with a nonproductive cough, and neurologic signs are not typical of bronchitis.
Acetaminophen administration: Acetaminophen is safe and commonly used to treat fever in toddlers. It is not associated with hepatic encephalopathy or neurologic complications seen in this scenario.
Oseltamivir administration: Though oseltamivir may cause gastrointestinal side effects like nausea or vomiting, it does not explain the altered mental status and lethargy. It is also unlikely to cause such a significant clinical deterioration on its own.

A. "Perform aerobic activities three times per week." B. "Soak in a hot bath." C. "Have your partner complete activities of daily living for you." D. "Schedule rest periods during the day."

Correct Answer is D

Explanation

Rationale:

A. "Perform aerobic activities three times per week.": While exercise can be beneficial, excessive aerobic activity may worsen fatigue in clients with MS. Low-impact and well-paced exercise is more appropriate.

B. "Soak in a hot bath.": Heat can exacerbate symptoms in clients with MS by increasing nerve conduction issues, potentially leading to worsening fatigue or vision changes.

C. "Have your partner complete activities of daily living for you.": Encouraging dependence can contribute to decreased function and self-esteem. Clients should be supported to remain as independent as possible within their limits.

D. "Schedule rest periods during the day.": Fatigue is a common symptom of MS. Rest periods help conserve energy and prevent exacerbation of symptoms, promoting better overall functioning.

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A nurse is caring for a client who is in the emergency department with multiple traumatic injuries following a motor-vehicle crash. Which of the following actions should the nurse take first?

Nursing Test Bank

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