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 D
Explanation
Choice A Reason: Providing written materials and visual aids is not necessary for a client who has hearing at 15 dB, which is considered normal hearing. Normal hearing ranges from 0 to 20 dB, meaning that the person can hear sounds that are as faint as 20 dB or less.
Choice B Reason: Using American Sign Language is not appropriate for a client who has hearing at 15 dB, which is considered normal hearing. American Sign Language is a form of communication that uses hand gestures, facial expressions, and body movements to convey meaning. It is mainly used by people who are deaf or hard of hearing.
Choice C Reason: Shouting at the client from 6 inches away is not advisable for a client who has hearing at 15 dB, which is considered normal hearing. Shouting can be perceived as rude or aggressive, and can damage the hearing of both the speaker and the listener.
Choice D Reason: Speaking to the client in an everyday conversational tone is the best action for a client who has hearing at 15 dB, which is considered normal hearing. Conversational speech ranges from 40 to 60 dB, meaning that the person can hear sounds that are as loud as 60 dB or less.
Correct Answer is D
Explanation
Choice A Reason: This is incorrect because nystagmus is not a response to stimuli, but a condition that causes involuntary eye movements. Nystagmus can be caused by various factors, such as inner ear disorders, brain lesions, or drug toxicity, but not necessarily by cervical spine injury.
Choice B Reason: This is incorrect because decorticate positioning is a response to stimuli that indicates damage to the cerebral cortex or the corticospinal tract. Decorticate positioning is characterized by flexion of the arms and extension of the legs. It does not indicate cervical spine injury, which affects the spinal cord below the brainstem.
Choice C Reason: This is incorrect because lack of any response to stimuli can indicate various levels of brain damage or coma, but not specifically cervical spine injury. Lack of any response can also be influenced by other factors, such as sedation, hypothermia, or shock.
Choice D Reason: This is correct because decerebrate positioning is a response to stimuli that indicates damage to the brainstem or the upper cervical spine. Decerebrate positioning is characterized by extension and outward rotation of the arms and legs. It indicates a severe and life-threatening injury that can impair vital functions, such as breathing and blood pressure.
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