22. A nurse is conducting a primary survey of a client who has sustained life-threatening injuries due to a motor-vehicle crash. Identify the sequence of actions the nurse should take. (Move the actions into the box on the right, placing them in the selected order of performance. Use all the steps.)

Establish IV access.

Open the airway using a jaw-thrust maneuver.

Remove clothing for a thorough assessment.

Perform a Glasgow Coma Scale assessment..

Determine effectiveness of ventilator efforts.

Answer and Explanation

The Correct Answer is B, E, A, D, C

B. The first priority in a primary survey is to open and maintain the airway; in a trauma client, this is done with a jaw-thrust maneuver to protect the cervical spine. E. After the airway is established, the nurse should assess breathing and determine the effectiveness of ventilatory efforts. A. Once airway and breathing are stabilized, circulation is addressed by establishing IV access for fluid or blood administration. D. Disability is assessed next using tools such as the Glasgow Coma Scale to evaluate neurologic status. C. Exposure is the final step; the nurse removes clothing to perform a thorough assessment while preventing hypothermia.

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Correct Answer is C

Explanation

A. Limiting ambulation is not a standard aneurysm precaution. While excessive activity should be avoided, strict bed rest is not always required unless specifically prescribed.
B. Protective isolation is not necessary for a client with an intracranial aneurysm, as the condition is not related to infection or immune suppression.
C. Minimizing environmental stimuli is essential to reduce stress, prevent increases in blood pressure, and decrease the risk of aneurysm rupture. A quiet, calm environment helps prevent sudden changes in intracranial pressure.
D. Elevating the head of the bed to 45 degrees may increase intracranial pressure. A more appropriate position is keeping the head of the bed elevated at 30 degrees to promote venous drainage while preventing excessive pressure on the aneurysm.

A. Remove clothing B. Maintain cervical spine precaution C. Perform a mental status exam D. Assess for facial lacerations

Correct Answer is B

Explanation

A. Remove clothing: While removing clothing may be necessary for a thorough assessment and treatment, maintaining cervical spine precaution takes precedence to prevent potential spinal cord injury in clients with a history of trauma, such as a fall from a significant height.

B. Maintain cervical spine precaution: Maintaining cervical spine precaution by stabilizing the cervical spine and immobilizing the neck is crucial to prevent further injury to the spinal cord in clients with a history of trauma until spinal injury is ruled out or managed.

C. Perform a mental status exam: While assessing the client's mental status is important for evaluating neurological function, it is not the first priority in a client with potential spinal cord injury following a fall.

D. Assess for facial lacerations: Assessing for facial lacerations is important for identifying and managing potential facial injuries, but it is not the first priority in the primary assessment of a client with a history of trauma and potential spinal cord injury.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has an intracranial aneurysm and requires aneurysm precautions. Which of the following interventions should the nurse take?

Correct Answer is C

Explanation

The nurse in the emergency department is caring for a client who has fallen 20 feet from a roof. While performing the primary assessment, what is the most important nursing intervention?

Correct Answer is B

Explanation

What will the nurse tell the patient who has cerebral atherosclerosis about taking clopidogrel?

A patient admitted with possible stroke has been aphasic for 3 hours and has a current blood pressure (BP) of 174/94 mm Hg. Which order by the health care provider should the nurse question?

A nurse enters a client's room and finds the client on the floor having a seizure. Which of the following medication would the nurse anticipate to administer?

Which intervention should the nurse include in the plan of care for a patient with new right- sided homonymous hemianopsia after a stroke?

A nurse is caring for a client who has an intracranial pressure (ICP) reading of 40 mm Hg. Which of the following findings should the nurse identify as a late sign of ICP? (Select all that apply.)

Which information about the patient who had a subarachnoid hemorrhage is most important to communicate to the health care provider?

A nurse is presenting discharge instructions to a client who has multiple sclerosis (MS). The client reports symptoms of diplopia, dysmetria, and sensory change. Which of the following nursing statements are appropriate?