A nurse in an emergency department is assisting with the care of a client who is unconscious and has trauma to multiple systems following a motor vehicle crash. Which of the following actions should the nurse take first?
Airway protection
Stabilizing cardiac arrhythmias
Preventing musculoskeletal disability
Decreasing intracranial pressure
The Correct Answer is A
Choice A reason: This action is correct because airway protection is the first priority for a client who is unconscious and has trauma to multiple systems. The nurse should assess the client's airway patency, breathing, and oxygenation, and intervene as needed to secure and maintain the airway. The nurse should also monitor the client for signs of aspiration, bleeding, or obstruction, and suction the airway as needed.
Choice B reason: This action is incorrect because stabilizing cardiac arrhythmias is not the first priority for a client who is unconscious and has trauma to multiple systems. The nurse should assess the client's circulation, blood pressure, and pulse, and intervene as needed to treat any arrhythmias, shock, or hemorrhage. However, this is not a priority over the client's airway, which is essential for survival.
Choice C reason: This action is incorrect because preventing musculoskeletal disability is not the first priority for a client who is unconscious and has trauma to multiple systems. The nurse should assess the client's mobility, sensation, and alignment, and intervene as needed to prevent or treat any fractures, dislocations, or nerve injuries. However, this is not a priority over the client's airway, which is essential for survival.
Choice D reason: This action is incorrect because decreasing intracranial pressure is not the first priority for a client who is unconscious and has trauma to multiple systems. The nurse should assess the client's level of consciousness, pupillary response, and neurological status, and intervene as needed to prevent or treat any increased intracranial pressure, cerebral edema, or brain injury. However, this is not a priority over the client's airway, which is essential for survival.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: This statement is true and should be included in the educational session. SDOH are the nonmedical factors that influence health outcomes, such as income, education, housing, food security, social inclusion, and access to health services. SDOH can affect a person's physical, mental, and social wellbeing, as well as their risk of developing certain diseases.
Choice B reason: This statement is false and should not be included in the educational session. SDOH are not determined by an individual’s ethnic background, but rather by the broader social, economic, and political context in which they live. However, ethnic background can influence how a person experiences SDOH, as some ethnic groups may face discrimination, racism, and marginalization that affect their access to resources and opportunities.
Choice C reason: This statement is false and should not be included in the educational session. Identifying SDOH does not increase disparities in health care, but rather helps to address them. Disparities in health care are the differences in the quality and accessibility of health services among different populations⁵. Identifying SDOH can help to understand the root causes of these disparities, and to design interventions that target the most vulnerable and disadvantaged groups.
Choice D reason: This statement is false and should not be included in the educational session. SDOH do not include psychological factors, but rather affect them. Psychological factors are the individual characteristics and behaviors that influence a person's mental health and wellbeing, such as personality, coping skills, self-esteem, and stress management. SDOH can influence psychological factors by creating stressful or supportive environments, and by facilitating or hindering access to mental health services.
Correct Answer is A
Explanation
Choice A reason: Telephone number is an acceptable identifier to use to identify the client. According to the Safety and Quality Improvement Guide Standard 5: Patient Identification and Procedure Matching, telephone number is one of the approved patient identifiers that can be used to reliably identify the individual as the person for whom the service or treatment is intended. Telephone number is a person specific identifier that is unlikely to be shared by another client.
Choice B reason: Room number is not an acceptable identifier to use to identify the client. According to the Safety and Quality Improvement Guide Standard 5: Patient Identification and Procedure Matching, room number is not an example of a unique patient identifier. Room number is not a person specific identifier, but a location specific identifier that can change or be assigned to another client.
Choice C reason: Medical condition is not an acceptable identifier to use to identify the client. According to the Safety and Quality Improvement Guide Standard 5: Patient Identification and Procedure Matching, medical condition is not an example of a unique patient identifier. Medical condition is not a person specific identifier, but a health specific identifier that can be common or vague among different clients.
Choice D reason: Home address is not an acceptable identifier to use to identify the client. According to the Safety and Quality Improvement Guide Standard 5: Patient Identification and Procedure Matching, home address is not an example of a unique patient identifier. Home address is not a person specific identifier, but a place specific identifier that can be shared or changed by the client.
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