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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Expecting a patient to display preinjury personality traits may not be feasible, as head injuries can lead to permanent personality changes.
B. Actively participating in rehabilitation is a realistic goal that focuses on the patient's engagement in the recovery process, which can improve functional outcomes.
C. Returning to a specific job, such as a corporate attorney, may not be a realistic goal initially and depends on the extent of cognitive recovery.
D. Recalling childhood events is not a priority goal in rehabilitation; functional and recovery-focused goals are more relevant.
Correct Answer is A
Explanation
A. A cold, pulseless foot indicates compromised blood flow, a medical emergency following an arteriogram. The nurse should immediately notify the physician to address potential vascular occlusion.
B. Elevating the limb can further impair circulation if blood flow is already compromised.
C. Covering the limb will not address the underlying issue of impaired circulation.
D. Repositioning may delay timely intervention in what may be a vascular emergency.
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