A client arrives to the emergency department after losing consciousness during a soccer game. Which of the following actions should the nurse take first?
Prepare the client for an X-Ray.
Calculate a Glasgow Coma Score.
Dim the lights and turn off the TV.
Provide analgesics.
The Correct Answer is B
Choice A reason: This is incorrect because preparing the client for an X-ray is not the first action that the nurse should take. An X-ray can help diagnose possible injuries or fractures, but it is not an urgent test. The nurse should first assess the client's level of consciousness and neurological status using a standardized tool such as the Glasgow Coma Scale.
Choice B reason: This is the correct answer because calculating a Glasgow Coma Score is the first action that the nurse should take. The Glasgow Coma Scale is a tool that measures the level of consciousness based on the eye-opening, verbal response, and motor responses. It can help determine the severity of brain injury and guide further interventions.
Choice C reason: This is incorrect because dimming the lights and turning off the TV are not the first actions that the nurse should take. These are environmental modifications that can help reduce sensory stimulation and prevent agitation or seizures, but they are not as important as assessing the level of consciousness and neurological status.
Choice D reason: This is incorrect because providing analgesics is not the first action that the nurse should take. Analgesics can help relieve pain and discomfort, but they can also alter the level of consciousness and mask neurological signs. The nurse should first assess the level of consciousness and neurological status, and then administer analgesics as prescribed.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A Reason: The client needs total nursing care is the expected outcome for a client who has a score of 6 on the Glasgow Coma Scale, which is a tool that measures the level of consciousness based on eye opening, verbal response, and motor response. A score of 6 indicates severe brain injury and coma, meaning that the client is unresponsive and dependent on others for all activities of daily living.
Choice B Reason: Indicates stable neurologic status is not the expected outcome for a client who has a score of 6 on the Glasgow Coma Scale, which indicates severe brain injury and coma. A stable neurologic status means that there are no changes in the level of consciousness, vital signs, or neurological signs.
Choice C Reason: The client has a decline in level of consciousness but is able to protect his airway is not the expected outcome for a client who has a score of 6 on the Glasgow Coma Scale, which indicates severe brain injury and coma. A decline in level of consciousness means that the client is less alert and responsive than normal, but still able to respond to stimuli and maintain airway patency.
Choice D Reason: The client is alert and oriented is not the expected outcome for a client who has a score of 6 on the Glasgow Coma Scale, which indicates severe brain injury and coma. Alert and oriented means that the client is fully awake and aware of person, place, time, and situation.
Correct Answer is ["A","B","C","D"]
Explanation
Choice A Reason: A distended bladder is one of the most common triggers of autonomic dysreflexia, which is a life-threatening condition that occurs in clients with spinal cord injuries above T-6. The bladder becomes overfilled and stimulates the sympathetic nervous system, causing vasoconstriction and hypertension.
Choice B Reason: A severe headache is one of the most common symptoms of autonomic dysreflexia, caused by the increased blood pressure in the brain. The headache may be accompanied by blurred vision, sweating, flushing, or anxiety.
Choice C Reason: An elevated blood pressure is the hallmark sign of autonomic dysreflexia, which can reach dangerously high levels and cause stroke, seizure, or death. The blood pressure may rise up to 300/160 mmHg or higher.
Choice D Reason: Nasal congestion is another possible trigger of autonomic dysreflexia, as it stimulates the nasal mucosa and activates the sympathetic nervous system. Other potential triggers include bowel impaction, skin irritation, tight clothing, or temperature changes.
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