A nurse is the first person on the scene of a motor vehicle accident.
The victim was the driver and is in the driver's seat unconscious.
The driver is breathing, has a pulse, and has minor lacerations on the head and face.
What action should the nurse implement first?

Stabilize the cervical spine until help arrives.

Control any external bleeding.

Use the head tilt chin lift method to maintain the airway.

Do not move the victim from the accident.

Answer and Explanation

The Correct Answer is A

Choice A rationale

Stabilizing the cervical spine prevents further spinal injury in case of vertebral damage, which is a priority when managing trauma patients until specialized medical care becomes available.

Choice B rationale

While controlling bleeding is essential, it is secondary to stabilizing the cervical spine since the airway and neurological protection take precedence in trauma protocols.

Choice C rationale

The head tilt chin lift method should not be used if cervical spine injury is suspected, as it may exacerbate potential damage to the vertebrae or spinal cord.

Choice D rationale

While not moving the victim is critical, stabilization of the cervical spine is the primary intervention to prevent further injury before emergency assistance arrives.

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Correct Answer is D

Explanation

Choice A rationale

Approaching the client from the unaffected side does not stimulate compensation or adaptation. It limits the opportunity for neural adjustment and rehabilitation to optimize functional use of the affected side.

Choice B rationale

Eye patches may address double vision but are ineffective in enhancing sensory perception compensation for hemianopsia. Rehabilitation focuses on improving spatial awareness, not restricting visual fields.

Choice C rationale

Muscle exercises aid ocular health but do not scientifically compensate for hemianopsia. Scanning techniques provide more effective sensory perception rehabilitation in spatial deficits caused by this condition.

Choice D rationale

Scanning techniques teach clients to move their head or eyes consciously to view their entire surroundings. This method compensates for sensory deficits, helping clients adapt effectively during rehabilitation. .

A. The client will exhibit no further episodes of short-term memory loss. B. The client will be able to return to their construction job in three weeks. C. The client will be emotionally stable and display pre-injury personality traits. D. The client will demonstrate consistent adherence to prescribed medications.

Correct Answer is D

Explanation

Choice A rationale

Absence of short-term memory loss may be desirable but depends on the injury's severity and therapy progression. Memory recovery is inconsistent and often impractical as a definitive short-term outcome goal.

Choice B rationale

Resuming construction work is unrealistic within three weeks considering potential cognitive and physical impairments. This task exceeds achievable rehabilitation milestones, emphasizing safety over rapid return to demanding roles.

Choice C rationale

Pre-injury personality traits may not fully return, as emotional and personality changes often result from cerebral insults. Emotional stability is feasible but pre-injury personality restoration is speculative.

Choice D rationale

Medication adherence reflects successful cognitive rehabilitation, supporting long-term health stability by preventing further complications. This outcome is realistic and appropriate for patients recovering from intracranial injuries. .

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A nurse is the first person on the scene of a motor vehicle accident.The victim was the driver and is in the driver's seat unconscious.The driver is breathing, has a pulse, and has minor lacerations on the head and face.What action should the nurse implement first?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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A nurse is the first person on the scene of a motor vehicle accident.
The victim was the driver and is in the driver's seat unconscious.
The driver is breathing, has a pulse, and has minor lacerations on the head and face.
What action should the nurse implement first?