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 D

Explanation

A. The client can follow simple motor commands: A GCS score of 5 for the best motor response indicates that the client can localize pain but cannot follow simple motor commands. A score of 6 or higher is required to demonstrate following commands.

B. The client is unable to make vocal sound: A GCS score of 5 for the best verbal response indicates incomprehensible sounds or no verbal response. It does not specifically indicate the client's ability to vocalize or make sounds.

C. The client opens his eyes when spoken to: A GCS score of 3 for eye opening indicates no eye opening even to painful stimuli. It does not suggest that the client opens his eyes when spoken to.

D. The client is unconscious: A GCS score of 3 for eye opening, 5 for best verbal response, and 5 for best motor response indicates severe neurological impairment, with the client being unresponsive to stimuli and unable to follow commands. Therefore, the appropriate conclusion is that the client is unconscious.

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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Naxlex Comprehensive Predictor Exams

A nurse is receiving a transfer report for a client who has a head injury. The client has a Glasgow Coma Scale (GCS) score of 3 for eye opening, 5 for best verbal response, and 5 for best motor response. Which of the following is an appropriate conclusion based on this data?

Correct Answer is D

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

A nurse is caring for a client who reports a throbbing headache and hypotension after a lumbar puncture. Which of the following actions is most likely to facilitate resolution of the headache?

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Which action should the nurse recognize as the highest priority for a patient who was admitted 16 hours earlier with a C5 spinal cord injury?

A patient with suspected meningitis is scheduled for a lumbar puncture. What action should the nurse take before the procedure?

An acute care nurse receives shift report for a client who has increased intracranial pressure. The nurse is told that the client demonstrates decorticate posturing. Which of the following findings should the nurse expect to observe when assessing the client?

The nurse identifies a patient with type 1 diabetes and a history of herpes simplex infection as being at risk for Bell's palsy. Which information should the nurse include in teaching the patient?

A nurse is caring for a client who has quadriplegia from a spinal cord injury and reports having a severe headache. The nurse obtains a blood pressure reading of 210/108 mm Hg and suspects the client is experiencing autonomic dysreflexia. Which of the following actions should the nurse take first?

A nurse is caring for a client who has a traumatic brain injury. Which of the following findings should the nurse identify as an indication of increased intracranial pressure (ICP)?