A client who is bleeding profusely from a stab wound is brought to the emergency department. Which type of assessment is most appropriate for this client?

Emergency

Time-lapse

Focused

Initial

Answer and Explanation

The Correct Answer is A

A. Emergency: This type of assessment is rapid and focuses on identifying and treating life-threatening conditions immediately, such as profuse bleeding from a stab wound.

B. Time-lapse: This assessment compares current client data to previous data to assess progress, which is not appropriate for an acute, life-threatening situation.

C. Focused: While this is a detailed assessment of a specific problem area, an emergency assessment is needed first for immediate threats to life.

D. Initial: This is a comprehensive assessment typically conducted when a client first enters a healthcare setting, but in an emergency, the focus shifts to immediate life-saving measures.

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Correct Answer is D

Explanation

A. Testing visual acuity: This assesses cranial nerve II (Optic nerve).

B. Observing for facial symmetry: This assesses cranial nerve VII (Facial nerve).

C. Eliciting the gag reflex: This assesses cranial nerves IX and X (Glossopharyngeal and Vagus nerves).

D. Checking the pupillary response to light: This assesses cranial nerve III (Oculomotor nerve), which controls pupil constriction and eye movements.

A. Sheepskin heel pad B. Abduction pillow C. Footboard D. Trochanter roll

Correct Answer is C

Explanation

A. Sheepskin heel pad: A sheepskin heel pad provides cushioning to prevent pressure ulcers but does not prevent plantar flexion contractures as it does not keep the foot in a neutral position.

B. Abduction pillow: An abduction pillow is used to maintain hip abduction and alignment, typically after hip surgery. It does not address foot positioning or prevent plantar flexion.

C. Footboard: A footboard helps maintain the feet in dorsiflexion, preventing plantar flexion contractures. It keeps the feet at a 90-degree angle to the legs, which is essential for preventing contractures.

D. Trochanter roll: A trochanter roll is used to maintain the alignment of the hips and prevent external rotation of the legs. It does not prevent plantar flexion contractures.

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A client who is bleeding profusely from a stab wound is brought to the emergency department. Which type of assessment is most appropriate for this client?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Correct Answer is C

Explanation

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