A nurse is caring for a client who was injured by a blast of high-order explosives. Medics report secondary injuries from the explosion. The nurse anticipates what type of injuries?

Blunt force trauma

Hollow organ damage

Post-trauma stress disorder

Penetrating injuries

Answer and Explanation

The Correct Answer is D

Choice A reason:

Blunt force trauma refers to injuries caused by impact with a blunt object, resulting in contusions, abrasions, lacerations, or fractures. While blunt force trauma can occur in explosions, it is typically associated with tertiary blast injuries, where the victim is thrown against a solid object. Secondary injuries from high-order explosives are more specifically related to penetrating injuries caused by flying debris and shrapnel.

Choice B reason:

Hollow organ damage is a type of primary blast injury caused by the overpressure wave from an explosion. This wave can cause significant damage to gas-filled organs such as the lungs, intestines, and ears. However, secondary injuries are not typically characterized by hollow organ damage. Secondary injuries are more commonly associated with penetrating trauma from debris and shrapnel.

Choice C reason:

Post-trauma stress disorder (PTSD) is a psychological condition that can develop after experiencing or witnessing a traumatic event. While PTSD is a serious and common consequence of exposure to explosions and other traumatic events, it is not classified as a secondary injury. Secondary injuries refer to physical injuries caused by flying debris and shrapnel, not psychological conditions.

Choice D reason:

Penetrating injuries are the hallmark of secondary blast injuries. These injuries occur when fragments from the explosive device or surrounding materials are propelled at high velocity, causing wounds that penetrate the skin and underlying tissues. These injuries can be severe and life-threatening, requiring immediate medical attention. The nurse should anticipate and be prepared to manage penetrating injuries in clients exposed to high-order explosives.

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Correct Answer is B

Explanation

Choice A reason:

Administering thrombolytics is not the first action the nurse should take. Thrombolytics are used to treat ischemic strokes, but their administration requires a thorough assessment and confirmation of the diagnosis through imaging studies. Immediate action is needed to ensure the client’s safety and initiate the stroke protocol.

Choice B reason:

Calling for help is the first action the nurse should take. The client is exhibiting signs of a possible stroke, and immediate medical intervention is required. Calling for help ensures that the stroke team or emergency response team is activated promptly to provide the necessary care.

Choice C reason:

Providing the client with water to test the gag reflex is not appropriate in this situation. The client may have difficulty swallowing, and giving water could lead to aspiration. The priority is to ensure the client’s safety and initiate the stroke protocol.

Choice D reason:

Performing carotid massage is not indicated for a client with new right-sided weakness and slurred speech. Carotid massage is used to manage certain types of arrhythmias, but it is not appropriate for suspected stroke. The focus should be on immediate assessment and intervention.

A. Administer an antipyretic. B. Complete a vascular assessment. C. Assess the cranial nerves. D. Decrease environmental stimuli.

Correct Answer is C

Explanation

Choice A reason:

Administering an antipyretic can help reduce fever, which is a common symptom of meningococcal meningitis. However, this action does not address the immediate need to assess the extent of neurological impairment. While fever management is important, it is not the first priority in this situation.

Choice B reason:

Completing a vascular assessment is important to evaluate the client’s circulatory status, especially if there are signs of septicemia. However, in the context of suspected meningococcal meningitis, the priority is to assess the neurological status to determine the extent of central nervous system involvement. This will guide further treatment and interventions.

Choice C reason:

Assessing the cranial nerves is crucial in a client with suspected meningococcal meningitis. This assessment helps determine the extent of neurological impairment and can provide critical information about the progression of the disease. Early identification of neurological deficits can guide immediate and appropriate interventions to prevent further complications.

Choice D reason:

Decreasing environmental stimuli can help reduce discomfort for the client, especially if they are experiencing photophobia or other sensory sensitivities. However, this action does not address the immediate need to assess the client’s neurological status. It is a supportive measure that can be implemented after more critical assessments are completed.

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A nurse is caring for a client who was injured by a blast of high-order explosives. Medics report secondary injuries from the explosion. The nurse anticipates what type of injuries?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse enters the room of a client and discovers the client with new right-sided weakness and slurred speech. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

Correct Answer is C

Explanation

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