A young adult is admitted to the emergency department after a motor vehicle crash. The client has severe pain in the right chest due to impact with the steering wheel. Which is the priority client goal?
Decrease chest pain
Reduce the client's anxiety
Maintain adequate circulating volume
Maintain adequate oxygenation
The Correct Answer is D
A. Decrease chest pain is important but not the highest priority. Managing pain can help with breathing, but oxygenation is the primary concern.
B. Reduce the client's anxiety is secondary to physiological needs. Anxiety can worsen dyspnea, but addressing oxygenation first is more critical.
C. Maintain adequate circulating volume is a priority if there is hemorrhage, but the question does not indicate bleeding. Oxygenation takes precedence in this case.
D. Maintain adequate oxygenation is the priority. Chest trauma can lead to pneumothorax, pulmonary contusion, or other complications that can impair gas exchange. Ensuring adequate oxygenation prevents hypoxia and respiratory failure, which are life-threatening.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. D-dimer, fibrinogen, and fibrin degradation products is correct because these tests reflect the excessive clotting and fibrinolysis seen in DIC: D-dimer: Elevated due to fibrin breakdown. Fibrinogen: Decreased due to excessive consumption. Fibrin degradation products (FDPs): Increased due to breakdown of fibrin clots.
B. Fibrin degradation products, lactic acid, and complete blood count is incorrect because lactic acid is more useful in sepsis evaluation, not DIC diagnosis.
C. Complete blood count, platelets, and prothrombin time is incorrect because while platelets may be low and PT may be prolonged, these tests alone are not specific for DIC.
D. Prothrombin time, form level, and d-dimer is incorrect because “form level” is not a relevant test, and PT alone is not sufficient for DIC diagnosis.
Correct Answer is C
Explanation
A. Initial stage of septic shock
Septic shock typically presents with warm, flushed skin in the early phase due to vasodilation. This client has cold and clammy skin, which is more consistent with hypovolemic shock.
B. Refractory stage of obstructive shock
Obstructive shock (e.g., from cardiac tamponade or pulmonary embolism) would present with jugular vein distention, muffled heart sounds, or severe respiratory distress, which are not seen in this case.
C. Progressive stage of hypovolemic shock
The client has classic signs of hypovolemic shock due to fluid loss (nausea, vomiting, diarrhea). The progressive stage is indicated by hypotension, tachycardia, and end-organ dysfunction (altered mental status, cool/clammy skin).
D. Compensatory stage of diabetic shock
"Diabetic shock" is not a standard classification of shock. The compensatory stage would still have an adequate blood pressure due to SNS activation, but this patient already has profound hypotension.
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