The nurse in the trauma unit has received a report on a client who has multiple injuries following a motor vehicle crash. Which of the following actions should the nurse plan to take first?

Check pupillary response to light.

Check the client's response to questions about place and time.

Assess the capillary refill.

Evaluate chest expansion.

Answer and Explanation

The Correct Answer is A

Choice A rationale:

(Correct Choice) Checking pupillary response to light is a critical first step in the assessment of a client with multiple injuries following a motor vehicle crash. Pupillary changes can indicate neurological issues, increased intracranial pressure, or damage to the brainstem. Rapidly assessing pupil size, equality, and reactivity helps identify potential life-threatening conditions.

Choice B rationale:

Checking the client's response to questions about place and time is important but not the highest priority in this scenario. Neurological and physiological stability should be addressed first to ensure the client's overall well-being.

Choice C rationale:

Assessing capillary refill is valuable in assessing peripheral circulation and hydration status. However, it is not the primary concern when dealing with a client who has potentially sustained traumatic injuries, where neurological and intracranial issues need to be ruled out or addressed urgently.

Choice D rationale:

Evaluating chest expansion is relevant for assessing lung function and detecting potential injuries like rib fractures. However, given the context of a trauma client, focusing on neurological assessment takes precedence over respiratory assessment in the immediate term.

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Correct Answer is B

Explanation

The correct answer is choice B. Necrotic subcutaneous tissue.

Choice A rationale:

Partial-thickness skin loss (Choice A) is characteristic of a stage II pressure ulcer, not a stage III ulcer. A stage II pressure ulcer involves the loss of the epidermis and possibly the dermis, resulting in a shallow open ulcer with a red-pink wound bed.

Choice B rationale:

Necrotic subcutaneous tissue is a manifestation of a stage III pressure ulcer. A stage III ulcer involves full-thickness skin loss where subcutaneous fat may be visible, but exposed bone or muscle is not yet present. Necrotic tissue in the wound bed indicates a more advanced level of tissue damage and the need for appropriate wound care to promote healing.

Choice C rationale:

Blood-filled blisters (Choice C) are not specific to pressure ulcers and are more commonly associated with friction or shear forces. These blisters are not indicative of a stage III pressure ulcer, which involves visible full-thickness tissue loss.

Choice D rationale:

Exposed bone (Choice D) is a characteristic of a stage IV pressure ulcer, not a stage III ulcer. A stage IV ulcer involves extensive tissue loss with exposure of muscle, tendon, or bone. This represents a severe level of tissue damage and requires intensive wound care and management.

A. "Cranberry juice can cause bad breath.". B. "You may experience bloating.". C. "Drinking cranberry juice daily can prevent recurrent urinary tract infections.". D. "Cranberry juice can lower cholesterol.".

Correct Answer is C

Explanation

Choice A rationale:

Cranberry juice causing bad breath is not a well-known side effect or outcome associated with its consumption. This information is not a commonly taught aspect of cranberry juice use.

Choice B rationale:

Bloating is not a common or widely recognized outcome of drinking cranberry juice. While cranberry juice might have some gastrointestinal effects, bloating is not a significant concern associated with its consumption.

Choice C rationale:

Informing the client that drinking cranberry juice daily can prevent recurrent urinary tract infections is accurate. Cranberry juice is often recommended for its potential to reduce the risk of urinary tract infections due to its anti-adhesive properties that may inhibit the adherence of bacteria to the urinary tract.

Choice D rationale:

Cranberry juice's effect on lowering cholesterol is not a well-established benefit of its consumption. Cholesterol management typically involves dietary changes, exercise, and sometimes medications, but cranberry juice is not a primary intervention for this purpose.

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The nurse in the trauma unit has received a report on a client who has multiple injuries following a motor vehicle crash. Which of the following actions should the nurse plan to take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is C

Explanation

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