The nurse in the emergency department is caring for a client with multiple injuries following a motor vehicle crash. The client lost consciousness. has an open fracture of the left tibia, and active bleeding at the fracture site. What is the priority nursing action?

Prepare for immediate surgery to repair the open fracture

Assess for pulses in the upper and lower extremities

Place a sterile pressure dressing on the open fracture

Maintain C-spine immobilization

Answer and Explanation

The Correct Answer is D

A. Prepare for immediate surgery to repair the open fracture
Surgery may be necessary, but it is not the immediate priority. The focus should be on stabilizing the client and preventing further injury.

B. Assess for pulses in the upper and lower extremities
Assessing circulation is important but is not the most immediate life-saving intervention. First, the client must be stabilized and bleeding controlled.

C. Place a sterile pressure dressing on the open fracture
While controlling bleeding is important, spinal immobilization takes precedence in trauma cases to prevent potential spinal cord injury.

D. Maintain C-spine immobilization
In a trauma patient with loss of consciousness, cervical spine injury must be assumed. Immobilization prevents further damage while other interventions are performed.

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

Explanation

A. Bend the client’s head toward their chest is correct because Brudzinski’s sign is tested by flexing the client’s neck and observing for an involuntary flexion of the hips and knees, which suggests meningeal irritation.

B. Ask the client to extend both arms above their head is incorrect; this is not part of the test for Brudzinski’s sign.

C. Place the client in a supine position is correct because the test must be done with the client lying flat on their back.

D. The nurse will place a hand behind the client’s head is correct because the nurse gently lifts the client’s head to assess for involuntary hip and knee flexion.

E. Assist the client to bend their knee 90 degrees is incorrect; knee bending is not required for Brudzinski’s sign but is part of Kernig’s sign testing.

A. Provide the daughter and client with nutritional counseling B. Interview the client alone and assess for abuse C. Take the history from the daughter because of the client's confusion D. Request a psychiatric evaluation for the client

Correct Answer is B

Explanation

A. Provide the daughter and client with nutritional counseling.

While nutrition is important, assessing for abuse is the priority.

B. Interview the client alone and assess for abuse.

The client’s reluctance and daughter’s interruptions suggest potential elder abuse.

C. Take the history from the daughter due to the client’s confusion.

The client should be interviewed alone first.

D. Request a psychiatric evaluation.

Confusion can result from dehydration or trauma, not necessarily a psychiatric disorder.

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The nurse in the emergency department is caring for a client with multiple injuries following a motor vehicle crash. The client lost consciousness. has an open fracture of the left tibia, and active bleeding at the fracture site. What is the priority nursing action?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is assessing a client for Brudzinskis sign as part of their neurologic assessment. Which of the following are appropriate actions by the nurse when performing this technique? SELECT ALL THAT APPLY

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

Explanation

Correct Answer is B

Explanation

The nurse in the emergency department is caring for a client with multiple injuries following a motor vehicle crash. The client lost consciousness. has an open fracture of the left tibia, and active bleeding at the fracture site. What is the priority nursing action?

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