The nurse is the first person on the scene of a motor vehicle crash. The victim was the driver and is in the driver's seat unconscious. The driver is breathing, has a pulse, and has minor lacerations on the head and face. What action should the nurse implement first?

Use the head tilt chin lift method to maintain the airway

Control any external bleeding

Do not move the victim from the accident

Stabilize the cervical spine until help arrives

Answer and Explanation

The Correct Answer is D

A. The head tilt chin lift method should be avoided due to the risk of aggravating a spinal injury; the jaw-thrust maneuver is safer if airway management is necessary.

B. While controlling bleeding is important, cervical spine stabilization takes priority in trauma with suspected spinal injury.

C. Not moving the victim is appropriate, but stabilizing the cervical spine provides active support to avoid further injury.

D. Stabilizing the cervical spine is crucial to prevent potential spinal cord damage in an unconscious trauma victim, particularly in a motor vehicle accident. This action helps prevent exacerbation of any spinal injury.

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Correct Answer is C

Explanation

A. Conjunctivitis (pink eye) is not a typical complication of Bell's Palsy.

B. Retinal detachment is unrelated to the incomplete eye closure seen in Bell’s Palsy.

C. Bell's Palsy often results in incomplete eye closure, which can lead to drying and irritation of the cornea, increasing the risk for corneal abrasions. An eye patch protects the cornea by helping the eye stay moist and protected from injury.

D. A chalazion is a small eyelid bump caused by blocked oil glands, not associated with Bell’s Palsy.

A. Nitroprusside B. Furosemide C. 3% Normal Saline D. Norepinephrine

Correct Answer is C

Explanation

A. Nitroprusside is a vasodilator and is not used for managing ICP; it can increase intracranial pressure if not carefully monitored.

B. Furosemide is a diuretic but is less effective for ICP reduction compared to hypertonic saline or mannitol.

C. Hypertonic saline (3% Normal Saline) is used to reduce intracranial pressure by drawing fluid out of the brain tissue and into the bloodstream, which can help prevent cerebral edema.

D. Norepinephrine is a vasopressor and is not used specifically to manage intracranial pressure.

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The nurse is the first person on the scene of a motor vehicle crash. The victim was the driver and is in the driver's seat unconscious. The driver is breathing, has a pulse, and has minor lacerations on the head and face. What action should the nurse implement first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse teaches a patient diagnosed with Bell's Palsy about the use of an eye patch to prevent which eye complication?

Correct Answer is C

Explanation

When considering the pharmacologic management of a patient who has sustained a traumatic head injury, the nurse can anticipate a prescription for which of the following medications to manage increases in intracranial pressure (ICP)?

Correct Answer is C

Explanation

The nurse is caring for a patient who will be discharged with a prescription for lisinopril. What discharge teaching should be provided related to this medication?

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The nurse suspects autonomic dysreflexia in the patient with a spinal cord injury at the level of C-7. After checking vital signs what are the priority nursing interventions?

The nurse is caring for a patient diagnosed with unstable angina who is prescribed metoprolol. The patient asks the nurse, "Why do I have to take this medication?" What response by the nurse is most accurate?

The nurse has established a goal to maintain intracranial pressure (ICP) within the normal range for the patient with an acute head injury. Which action(s) should the nurse take to achieve this goal? (SELECT ALL THAT APPLY)

The nurse is caring for a patient who has sustained eye trauma as a result of a motor vehicle crash (MVC). Which intervention should the nurse provide regarding a foreign body?

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