The nurse is caring for a client in neurogenic shock following an overdose of anti-anxiety medication. When assessing this client, the nurse should recognize what characteristic of neurogenic shock?

Signs of sympathetic stimulation

Hypertension

Cool, moist skin

Bradycardia

Answer and Explanation

The Correct Answer is D

A. Neurogenic shock is characterized by the loss of sympathetic tone, leading to parasympathetic predominance. Therefore, signs of sympathetic stimulation, such as tachycardia or sweating, are not present.
B. Neurogenic shock typically causes hypotension, not hypertension, due to vasodilation and decreased systemic vascular resistance.
C. Cool, moist skin is more commonly seen in hypovolemic or septic shock due to peripheral vasoconstriction. In neurogenic shock, vasodilation leads to warm, dry skin.
D. Bradycardia is a hallmark of neurogenic shock due to unopposed parasympathetic stimulation resulting from the loss of sympathetic nervous system control.

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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. Time of the burn B. Depth of the burn C. Cause of the burn D. Location of the burn

Correct Answer is B

Explanation

A. The time of the burn helps in understanding how long the client has been exposed and may influence the assessment of burn progression, but it does not directly determine the severity.
B. The depth of the burn is the primary factor in assessing burn severity. It determines the level of tissue damage and guides treatment decisions. Depth classifications include superficial, partial-thickness, and full-thickness burns.
C. The cause of the burn is important for treatment considerations and understanding the mechanism of injury but does not impact the assessment of burn severity.
D. The location of the burn affects the potential for complications and functional impairment but is secondary to the depth in determining overall burn severity.

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The nurse is caring for a client in neurogenic shock following an overdose of anti-anxiety medication. When assessing this client, the nurse should recognize what characteristic of neurogenic shock?

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