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The nurse is caring for a client who received a blunt force injury to zone II of the neck. Which assessment finding should the nurse report to the physician IMMEDIATELY?

Deep purple erythema

Facial nerve deficits

Dysphonia or dysphagia

Heart rate of 10 and blood pressure of 96/68

Answer and Explanation

The Correct Answer is C

A. Deep purple erythema

This suggests bruising or possible hematoma formation, which is concerning but may not be immediately life-threatening.

B. Facial nerve deficits

This indicates nerve injury, which is serious but may not be immediately life-threatening.

C. Dysphonia or dysphagia

Dysphonia (difficulty speaking) or dysphagia (difficulty swallowing) are signs of airway compromise or injury to structures involved in breathing and swallowing. This requires immediate attention.

D. Heart rate of 100 and blood pressure of 96/68

These vital signs indicate tachycardia and borderline hypotension, which are concerning, but the airway compromise (option C) is more immediately life-threatening.

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Correct Answer is B

Explanation

A. Hydrocodone and acetaminophen 5/500 mg PO
Opioids are generally ineffective for neuropathic pain, and trigeminal neuralgia is best managed with anticonvulsants.

B. Carbamazepine 200 mg PO
Carbamazepine (an anticonvulsant) is the first-line treatment for trigeminal neuralgia. It helps reduce nerve excitability and pain episodes.

C. Methotrexate 5 mg PO
Methotrexate is an immunosuppressant and chemotherapy drug, not used for trigeminal neuralgia.

D. Linezolid 600 mg PO
Linezolid is an antibiotic used for bacterial infections, not neuropathic pain.

A. Gently cleanse the wounds with warm soapy water B. Remove blistered skin and cover with a dry dressing C. Apply saline soaked wet-to-dry dressings D. Cover with a clean dry sheet to prevent hypothermia

Correct Answer is D

Explanation

A. Gently cleanse the wounds with warm soapy water

Initial burn care focuses on preventing hypothermia and infection. Cleaning is usually performed in a controlled setting like a burn unit, not in the emergency phase.

B. Remove blistered skin and cover with a dry dressing

Blisters should not be removed in the initial phase unless they are large and tense. Removal increases the risk of infection.

C. Apply saline-soaked wet-to-dry dressings

Wet dressings can lead to hypothermia in burn patients, which worsens outcomes. Dry coverings are preferred.

D. Cover with a clean dry sheet to prevent hypothermia

Burn patients lose heat rapidly due to loss of skin integrity. Covering with a clean, dry sheet helps prevent hypothermia and infection before transfer.

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The nurse is caring for a client who received a blunt force injury to zone II of the neck. Which assessment finding should the nurse report to the physician IMMEDIATELY?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

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Correct Answer is D

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