An 82-year-old client who sustained a head injury in a motor vehicle crash while on warfarin therapy is admitted for observation. The nurse is providing teaching regarding the client's diagnosis of a subdural hematoma. Which of the following statements by the client indicates an understanding of teaching?

"I developed a hematoma because an artery burst in my brain when my head hit the windshield."

"I developed a bleed in my brain because my platelets were too high."

"I developed a hematoma because I take a blood thinner and my head hit the windshield."

"I developed a hematoma because my bleeding times were too low and I hit my head."

Answer and Explanation

The Correct Answer is C

A. A subdural hematoma is typically caused by venous bleeding, not arterial bleeding. An arterial rupture would more likely cause an epidural hematoma, which is not the case here.
B. High platelet counts are not commonly associated with the formation of subdural hematomas. Subdural hematomas are usually due to bleeding related to anticoagulant use or trauma.
C. Taking a blood thinner like warfarin increases the risk of bleeding and hematoma formation, particularly when combined with head trauma. This statement correctly links the anticoagulant therapy and head injury as contributing factors to the subdural hematoma.
D. Low bleeding times are not a cause of hematomas. In fact, elevated bleeding times due to anticoagulant therapy would increase the risk of bleeding, not low bleeding times.

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Correct Answer is A

Explanation

A. The first priority in this situation is to open the client's airway using the jaw-thrust maneuver. This technique is preferred for clients with suspected spinal injuries to avoid further spinal cord damage. Ensuring the airway is open and providing oxygenation are immediate life-saving actions.
B. Checking cranial nerve function, including assessing pupils, is important for evaluating neurological status but is not the first action when the client is not breathing. Ensuring the airway is open and providing oxygenation is the priority.
C. While placing the client in a rigid cervical collar is important for stabilizing the spine and preventing further injury, it should be done after ensuring the airway is clear. The immediate concern is to address the client's non-breathing status.
D. Evaluating the client for brain injury is important for overall assessment but is secondary to addressing the immediate life threat of not breathing. Ensuring the airway is open and then stabilizing the spine is the priority.

A. Intravenous fluid administration B. Ice packs to affected area 15 min on/15 min off C. Ambulation in hallway with supervision D. Hydromorphone intravenously (IV) for pain E. Acetaminophen orally (PO) for pain F. Oxygen 2 L/min via nasal cannula

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"B"},"C":{"answers":"B"},"D":{"answers":"A"},"E":{"answers":"B"},"F":{"answers":"B"}}

Explanation

Intravenous fluid administration is anticipated as hydration can help reduce the viscosity of sickled cells, improving circulation and potentially reducing vaso-occlusive events.

Ice packs to the affected area are nonessential and could potentially be contraindicated, as cold can cause vasoconstriction and may exacerbate pain.

Ambulation is nonessential during acute pain episodes and should be encouraged when the patient is comfortable and pain is controlled.

Hydromorphone IV for pain is anticipated because it is a stronger opioid than morphine and may be necessary if the pain is unresponsive to oral morphine sulfate.

Acetaminophen PO for pain is nonessential in this scenario as it is unlikely to provide adequate pain relief for severe vaso-occlusive pain.

Oxygen therapy is nonessential given the client's SpO2 is 95% on room air, indicating adequate oxygen saturation; however, it may be considered if there is evidence of hypoxia or respiratory distress. It is crucial to monitor the client's response to pain management interventions and adjust the treatment plan accordingly.

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Naxlex Comprehensive Predictor Exams

A nurse witnesses a motor vehicle crash and finds a client who is not breathing. The nurse suspects the client has a cervical vertebrae fracture. Which of the following actions should the nurse take first?

Correct Answer is A

Explanation

A nurse is caring for a 38-year-old client who presents to the emergency department (ED) in pain. Exhibits For each potential healthcare provider's prescription, click to specify if the potential prescription is anticipated, nonessential, or contraindicated for the client.

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"B"},"C":{"answers":"B"},"D":{"answers":"A"},"E":{"answers":"B"},"F":{"answers":"B"}}

Explanation

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