The nurse is caring for a patient who was in a motor vehicle accident that resulted in cervical trauma to C4. Which assessment is the priority?
Respirations
Pulse
Temperature
Blood Pressure
The Correct Answer is A
A. Respirations: C4 injuries compromise the phrenic nerve, which controls the diaphragm. A high cervical spine injury can lead to respiratory failure, making airway and breathing the top priority.
B. Pulse: While monitoring circulation is important, breathing takes priority in a C4 injury due to the risk of respiratory paralysis.
C. Temperature: Temperature regulation may be affected due to autonomic dysfunction, but airway and breathing remain the priority.
D. Blood Pressure: While spinal cord injuries can cause neurogenic shock (low BP, bradycardia), ensuring airway and breathing comes first.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. "Have you had any changes in your diet?" While diet can impact skin health, this question is not the most relevant for an immediate skin assessment. More direct questions about onset, symptoms, and exacerbating factors should be prioritized.
B. "Does your skin condition keep you awake at night?" Pruritus (itching), pain, or discomfort from a skin condition can disrupt sleep. Asking this helps assess the impact on daily life and quality of sleep.
C. "How does your skin condition make you feel?" Skin conditions can affect self-esteem and mental health. This question is therapeutic and appropriate to assess emotional impact.
D. "How do you handle stress?" Many skin conditions, such as eczema and psoriasis, worsen with stress. This question is relevant for identifying triggers.
Correct Answer is C
Explanation
A. Assess the pedal pulses for a full minute. Pedal pulses assess circulation to the lower extremities and are not related to confirming an irregular heart rate.
B. Assess the apical pulse with a Doppler device. A Doppler is not typically necessary to assess the apical pulse unless pulses are difficult to detect due to poor circulation.
C. Assess the apical pulse for a full minute. When an irregular radial pulse is detected, the most accurate way to assess heart rate and rhythm is by auscultating the apical pulse for a full minute. This helps determine the presence of arrhythmias.
D. Assess the pedal pulses with a Doppler device. Checking pedal pulses with a Doppler is useful for assessing circulation in the lower extremities but does not help confirm an irregular heart rate.
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