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.
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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Related Questions
Correct Answer is D
Explanation
A. Bradykinesia: Bradykinesia refers to slowness of movement and is commonly associated with Parkinson's disease. It is not typically assessed through neck flexion in the context of meningitis.
B. Kernig's sign: Kernig's sign is assessed by flexing the patient's hip and knee and then attempting to extend the knee. Resistance or pain during knee extension suggests meningeal irritation, but it does not involve the involuntary flexion of the legs.
C. Nuchal rigidity: Nuchal rigidity refers to stiffness and pain in the neck and inability to flex the neck forward due to inflammation of the meninges. While it is related to meningitis, it does not involve involuntary flexion of the legs.
D. Brudzinski's sign: Brudzinski's sign is a physical exam finding where passive flexion of the neck results in involuntary flexion of the hips and knees. It is a classic sign of meningeal irritation, often seen in meningitis.
Correct Answer is C
Explanation
A. Start a labetalol drip to keep BP less than 140/90 mm Hg: This order is appropriate because it aims to lower the patient's blood pressure to a target range recommended for acute ischemic stroke management.
B. Keep the head of the bed elevated at least 30 degrees: This intervention is part of stroke management to prevent aspiration and improve cerebral perfusion.
C. Begin tissue plasminogen activator (tPA) intravenously per protocol: The nurse should question this order because tissue plasminogen activator (tPA) is contraindicated in patients with stroke who have had symptoms for more than 3 hours or have unknown time of onset, as in this case where the patient has been aphasic for 3 hours. Administering tPA in this situation could increase the risk of bleeding complications without providing benefit.
D. Infuse normal saline intravenously at 75 mL/hr: This order is appropriate for maintaining hydration and intravascular volume in the acute care setting.
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