The nurse is caring for a client who was admitted to the emergency department following a head-on motor vehicle crash. The client is unresponsive, has respirations of 22/min, and a bleeding laceration to the forehead. Which of the following is the priority nursing action at this time?

Establish IV access and start fluid replacement.

Insert nasogastric tube.

Keep neck stabilized.

Monitor pulse and blood pressure frequently.

Answer and Explanation

The Correct Answer is C

Choice A Reason:
Establishing IV access and starting fluid replacement is important for maintaining hemodynamic stability, especially if there is significant blood loss. However, it is not the immediate priority in this scenario. Ensuring the neck is stabilized takes precedence to prevent potential spinal cord injury.

Choice B Reason:
Inserting a nasogastric tube is not a priority in the acute management of a trauma patient with a head injury. This procedure can be deferred until the patient's airway and cervical spine are secured and other life-threatening conditions are addressed.

Choice C Reason:
Keeping the neck stabilized is the priority action. In a trauma patient with a head injury, there is a high risk of cervical spine injury. Stabilizing the neck prevents further damage to the spinal cord, which could result in paralysis or other severe complications.

Choice D Reason:
Monitoring pulse and blood pressure frequently is essential for assessing the patient's hemodynamic status. However, it is not the immediate priority over stabilizing the cervical spine. Once the neck is stabilized, continuous monitoring of vital signs should follow.

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

Explanation

Choice A Reason:
Neck vein distention is a common finding in patients with mitral valve insufficiency. This condition leads to increased pressure in the left atrium, which can back up into the pulmonary veins and subsequently the right side of the heart, causing jugular venous distention.

Choice B Reason:
Splenomegaly is not typically associated with mitral valve insufficiency. It is more commonly seen in conditions like liver disease, hematologic disorders, and infections. Mitral valve insufficiency primarily affects the heart and lungs rather than the spleen.

Choice C Reason:
Petechiae are small, red or purple spots caused by bleeding into the skin. They are not a common finding in mitral valve insufficiency. Petechiae are more often associated with conditions that affect platelet function or coagulation, such as thrombocytopenia or vasculitis.

Choice D Reason:
An S4 heart sound, also known as an atrial gallop, can be heard in patients with mitral valve insufficiency. This sound occurs due to the atria contracting forcefully to overcome a stiff or hypertrophic ventricle, which is often a result of chronic pressure overload from the regurgitant flow.

A. Elevate the client's head on two pillows. B. Keep the client well hydrated. C. Decrease the noise level in the client's room. D. Suction the endotracheal tube frequently.

Correct Answer is C

Explanation

Choice A Reason:
Elevating the client's head on two pillows can help reduce ICP by promoting venous drainage from the brain. However, it is important to ensure that the head is not elevated too high, as this can impede venous return and potentially increase ICP. The recommended elevation is typically 30 degrees. While this intervention is beneficial, it is not the most critical action compared to reducing environmental stimuli.

Choice B Reason:
Keeping the client well hydrated is essential for overall health, but excessive hydration can increase ICP by increasing the volume of cerebrospinal fluid and blood within the cranial vault. Fluid management must be carefully monitored to avoid exacerbating ICP. Therefore, while hydration is important, it must be balanced and not excessive.

Choice C Reason:
Decreasing the noise level in the client's room is crucial for minimizing external stimuli that can increase ICP. Noise and other environmental stressors can lead to increased agitation and stress, which in turn can elevate ICP. Creating a calm and quiet environment helps in maintaining a stable ICP and is a non-invasive, easily implementable intervention.

Choice D Reason:
Frequent suctioning of the endotracheal tube can cause transient increases in ICP due to the stimulation and potential for coughing. While suctioning is necessary to maintain airway patency, it should be performed judiciously and only when clinically indicated. Over-suctioning can lead to spikes in ICP and should be avoided.

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The nurse is caring for a client who was admitted to the emergency department following a head-on motor vehicle crash. The client is unresponsive, has respirations of 22/min, and a bleeding laceration to the forehead. Which of the following is the priority nursing action at this time?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

James, the ICU nurse, is assessing a client with mitral valve insufficiency. Which of the following findings should the nurse expect?

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

Explanation

A nurse is caring for a client who has a closed-head injury with elevated ICP readings ranging from 16 to 22 mm Hg. Which of the following actions should the nurse take to decrease the potential for raising the client's ICP?

Correct Answer is C

Explanation

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