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 ["A","B","C","D","E"]

Explanation

Rationale:

A. Sudden muscular contractions: Antipsychotics like haloperidol and chlorpromazine can cause extrapyramidal symptoms (EPS), including acute dystonia, which manifests as sudden, involuntary muscle contractions typically affecting the face, neck, or back.

B. Orthostatic hypotension: Chlorpromazine, a low-potency typical antipsychotic, often causes orthostatic hypotension due to its alpha-adrenergic blockade, increasing fall risk, especially in older adults or those new to therapy.

C. Anticholinergic effects: These include dry mouth, blurred vision, constipation, and urinary retention. Chlorpromazine is particularly known for its anticholinergic side effects due to its action on muscarinic receptors.

D. Tremors: Tremors are part of parkinsonian side effects, another form of EPS commonly caused by haloperidol. They result from dopamine blockade in the nigrostriatal pathway.

E. Sedation: Both haloperidol and chlorpromazine can cause sedation. Chlorpromazine is especially sedating due to its histamine (H1) receptor blockade, which depresses the CNS.

F. Increased urination: Not typically associated with these medications. In fact, anticholinergic effects from chlorpromazine more often lead to urinary retention, not increased urination.

A. The person holding financial power of attorney will make health care decisions based on the client's advance directives. B. The client has the right to refuse medical treatment, even if health care providers recommend it. C. The client's eldest adult child has the right to change advance directives in an end-of-life situation. D. If the client's advance directives are in writing and notarized, the client cannot change it in the future.

Correct Answer is B

Explanation

Rationale:

A. The person holding financial power of attorney will make health care decisions based on the client's advance directives: A financial power of attorney manages financial matters, not health care decisions. A separate designation such as a health care proxy or medical power of attorney is needed for making medical decisions.

B. The client has the right to refuse medical treatment, even if health care providers recommend it: Under the Patient Self-Determination Act (PSDA), clients have the legal right to make autonomous decisions about their care, including the right to refuse or discontinue treatment, regardless of medical advice.

C. The client's eldest adult child has the right to change advance directives in an end-of-life situation: Advance directives reflect the client’s own decisions. No family member, regardless of birth order, has the legal authority to change them unless specifically authorized as a health care proxy and even then, only if the client is incapacitated.

D. If the client's advance directives are in writing and notarized, the client cannot change it in the future: Clients can revise or revoke advance directives at any time, as long as they remain mentally competent. Notarization does not make the document legally fixed or unchangeable.

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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

Naxlex Comprehensive Predictor Exams

The nurse continues to care for the client.Exhibits The nurse administers the client's scheduled medication. Which of the following adverse effects of the medication should the nurse monitor the client for? Select all that apply.

Correct Answer is ["A","B","C","D","E"]

Explanation

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Correct Answer is B

Explanation

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