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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Control dysrhythmias and decrease the heart rate
Controlling dysrhythmias is important, but decreasing heart rate is not always the goal, as a compensatory tachycardia may be necessary for perfusion.
B. Decrease cardiac workload and increase systemic perfusion
Cardiogenic shock results from impaired cardiac output. The goal is to reduce the heart’s workload (e.g., by reducing afterload) while improving systemic perfusion.
C. Improve oxygen exchange and decrease urinary output
Oxygenation is important, but decreased urinary output indicates poor renal perfusion and worsening shock, which is not a goal of treatment.
D. Decrease the blood pressure and respiratory rate
In cardiogenic shock, blood pressure is already low. The goal is to maintain adequate perfusion, not to further reduce BP.
Correct Answer is C
Explanation
A. Review dietary approaches to stop hypertension (DASH) choices in a client with primary HTN
Dietary education requires nursing judgment and assessment, which are outside the CNA’s scope of practice. This should be done by the RN or a dietitian.
B. With one other CNA, logroll a client who has had a bicycle accident
Logrolling is required in patients with spinal precautions, and an RN or physical therapist should oversee or perform the procedure to ensure proper spinal alignment.
C. Obtain a weight on a newly admitted client with diabetes
Measuring weight is within a CNA’s scope of practice, and it does not require clinical judgment. The CNA can obtain the weight and report findings to the RN.
D. Assist a client to the bathroom 1 hour after a lumbar puncture
A client who has undergone a lumbar puncture is at risk for post-procedure headaches and hypotension due to cerebrospinal fluid loss. The RN should assess the client first before allowing ambulation.
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