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 C
Explanation
Choice A Reason: Inserting a nasal swab to observe the fluid is contraindicated, as it can introduce infection or increase intracranial pressure. The fluid can be tested for glucose or halo sign to confirm cerebrospinal fluid (CSF) leakage.
Choice B Reason: Suctioning the nose gently with a bulb syringe is also contraindicated, as it can create negative pressure and increase CSF leakage or cause meningitis.
Choice C Reason: This is the correct answer because allowing the drainage to drip onto a sterile gauze pad can prevent contamination and facilitate observation of the amount and characteristics of the fluid.
Choice D Reason: Inserting sterile packing into the nares is not recommended, as it can obstruct the drainage and increase intracranial pressure or infection risk.
Correct Answer is D
Explanation
Choice A Reason: Head trauma is not one of the top causes of blindness in the United States, but rather a possible cause of it. Head trauma can damage the optic nerve, retina, or brain, leading to vision loss or impairment.
Choice B Reason: Cardiovascular disease is not one of the top causes of blindness in the United States, but rather a risk factor for it. Cardiovascular disease can affect the blood supply and oxygen delivery to the eyes, leading to conditions such as glaucoma, macular degeneration, or retinal vein occlusion.
Choice C Reason: Syphilis is not one of the top causes of blindness in the United States, but rather a rare cause of it. Syphilis is a sexually transmitted infection that can affect the eyes, leading to inflammation, scarring, or detachment of the retina.
Choice D Reason: This is the correct choice. Diabetic retinopathy is one of the top causes of blindness in the United States, affecting about 4.1 million adults. Diabetic retinopathy is a complication of diabetes that damages the blood vessels in the retina, leading to bleeding, swelling, or leakage of fluid. It can cause blurred vision, floaters, or blindness if left untreated.
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