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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 ["A","B"]

Explanation

A. Distributive shock

Severe burns lead to systemic inflammatory response syndrome (SIRS), causing massive vasodilation, similar to septic shock (a type of distributive shock).

D. Hypovolemic shock

Fluid loss from burns leads to hypovolemic shock, which is the most common type of shock seen in burn patients.

B. Cardiogenic shock

Cardiogenic shock is caused by heart failure and is not a primary concern in burn injuries.

C. Obstructive shock

Obstructive shock (e.g., tension pneumothorax, cardiac tamponade) does not occur in burn patients unless another condition is present.

E. Neurogenic shock

Neurogenic shock occurs from spinal cord injuries, not burns.

A. Laterally on the left side with a pillow under the head and the right arm and hand hyperextended B. Supine with a pillow under the head, and elevate the right hand and arm on a pillow C. Semi-Fowler's position without a pillow under the head, and the right arm and hand elevated on a pillow D. Prone without a pillow, and with the right arm and hand flexed in a position of comfort and elevated on a pillow

Correct Answer is C

Explanation

A. Laterally on the left side

Lateral positioning may not fully prevent contractures.

B. Supine with a pillow under the head

A pillow under the head can cause neck contractures.

C. Semi-Fowler’s without a pillow, right arm & hand elevated

Prevents contractures and promotes drainage of edema.

D. Prone without a pillow

Prone position increases discomfort and risk of respiratory complications.

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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?

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Naxlex Comprehensive Predictor Exams

The nurse is caring for a patient with major bums Total Body Surface Area (TBSA) of 63%. The nurse understands that this patient is at the highest risk for the combination of which types of shock? (Select All that Apply.)

Correct Answer is ["A","B"]

Explanation

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Correct Answer is C

Explanation

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