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. Inspect muscle symmetry in the upper and lower extremities
While muscle symmetry is important, it only assesses muscle mass and atrophy, not motor function or coordination.
B. The RN asks the client to squeeze their hand or show 2 fingers and lift their arm off the bed
This assesses motor strength and coordination, which are key components of motor ability. Handgrip strength and upper limb movement provide important information about neurological function.
C. Check plantar response and deep tendon reflex testing bilaterally
These tests assess reflexes and neurological pathways rather than motor function and coordination.
D. Comparative cranial nerve assessments and ability to follow simple commands
While following commands assesses cognition, it does not directly evaluate muscle strength or motor ability.
Correct Answer is B
Explanation
A. is expected to be decreased for three to five days.
In the initial stages following severe burn injury, there is often oliguria (low urine output), but this is typically followed by diuresis (increased urine output) after the first 24-48 hours, not a decrease over 3-5 days.
B. will be reduced in the first 24-48 hours and will then increase.
In the first 24-48 hours following a severe burn injury, the body may undergo a state of hypovolemia and oliguria. As fluid resuscitation begins, urine output typically increases.
C. output will be greatest in the first 24 hours after the burn injury.
Although urine output may increase with proper fluid resuscitation, it is not usually greatest in the first 24 hours; the increase typically happens after the initial resuscitation period.
D. will be elevated due to the amount of intravenous fluids administered during the initial phases of treatment.
While fluid resuscitation leads to an increase in urine output after the first 24-48 hours, it is not expected to be elevated right away. The kidneys may initially respond with oliguria.
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