A nurse in the emergency department is assessing a client who was brought in by a neighbor after falling down suddenly while walking. Which of the following assessments are the priority for the nurse to complete?(Select All that Apply.)
Muscle strength
Facial symmetry
Peripheral pulses
Vision changes
Aphasia
Correct Answer : A,B,D
Choice A Reason:
Muscle strength is correct. Assessing muscle strength is essential to determine if there are any neurological deficits or weakness that could indicate a neurological condition or injury. Sudden falls can be indicative of various neurological issues, such as stroke or transient ischemic attack (TIA). Assessing muscle strength helps identify any motor impairments or weakness that could contribute to the fall.
Choice B Reason:
Facial symmetry is correct. Assessing facial symmetry is crucial to identify any signs of facial droop, which could indicate a neurological deficit such as a stroke or Bell's palsy. Facial asymmetry may suggest damage to the facial nerve or other neurological issues.
Choice C Reason:
Peripheral pulses is incorrect. While assessing peripheral pulses is important for evaluating circulation, it may not be the priority assessment in this scenario where the client has suddenly fallen and may be experiencing neurological symptoms. Neurological deficits, such as weakness or changes in facial symmetry, vision, or speech, are more indicative of acute neurological issues like stroke or transient ischemic attack (TIA), which require immediate attention and intervention. In emergency situations, prioritizing assessments related to potential life-threatening conditions such as neurological deficits takes precedence over assessing peripheral pulses.
Choice D Reason:
Vision changes is correct. Assessing for vision changes is important to identify any visual disturbances or deficits that could contribute to falls or indicate underlying neurological issues such as a stroke or transient ischemic attack (TIA). Visual disturbances may include blurriness, double vision, or loss of vision in one or both eyes.
Choice E Reason:
Aphasia is incorrect. Assessing for aphasia, which is the inability to understand or express speech, is essential to identify any language deficits that could indicate a neurological condition such as a stroke. Aphasia may present as difficulty speaking, understanding language, or both.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A Reason:
Previous stroke is not directly associated with an increased risk of status asthmaticus. While individuals with certain medical conditions, such as neurological disorders, may have an increased risk of complications from severe asthma exacerbations, a previous stroke alone is not a recognized risk factor for status asthmaticus.
Choice B Reason:
Irritants and hypersensitivity to medications, may trigger asthma exacerbations, but they are not specific risk factors for status asthmaticus. Asthma exacerbations triggered by irritants or medications can typically be managed with appropriate treatment measures and do not necessarily lead to status asthmaticus.
Choice C Reason:
Previous intubation due to status asthmaticus episode is correct. Status asthmaticus is a severe and life-threatening asthma exacerbation that is unresponsive to standard treatment measures such as bronchodilators and corticosteroids. It is characterized by prolonged and severe bronchospasm, airway inflammation, and respiratory distress.
Choice D Reason:
Bronchial pneumonia is not a known risk factor for status asthmaticus. Bronchial pneumonia, or pneumonia affecting the bronchi and lungs, is a separate respiratory condition caused by bacterial, viral, or fungal infections. While pneumonia can exacerbate asthma symptoms in individuals with asthma, it is not specifically associated with an increased risk of status asthmaticus.
Correct Answer is A
Explanation
Choice A Reason:
Smoking tobacco is the primary and most significant risk factor for emphysema. Tobacco smoke contains harmful chemicals and toxins that directly damage the lungs. Chronic exposure to cigarette smoke leads to inflammation and destruction of lung tissue, particularly the alveoli, contributing to the development of emphysema.
Choice B Reason:
Between 20 to 30 years of age. While smoking at any age is harmful to lung health, the risk of developing emphysema increases with prolonged exposure to tobacco smoke over many years. Emphysema is typically a disease of middle to older age, with symptoms often appearing after years of smoking.
Choice C Reason:
Asthma is a chronic inflammatory condition of the airways characterized by reversible airflow obstruction and airway hyperresponsiveness. While asthma and emphysema are both respiratory diseases, they have distinct pathophysiological mechanisms and risk factors. Asthma is not a direct cause of emphysema, although some individuals with poorly controlled asthma may develop chronic obstructive pulmonary disease (COPD), which includes emphysema as one of its components.
Choice D Reason:
Pollution is not correct. Environmental pollution, including air pollution from industrial emissions, vehicle exhaust, and particulate matter, can contribute to respiratory problems and exacerbate pre-existing lung conditions. While exposure to pollution can worsen respiratory symptoms and lung function, it is not the primary cause of emphysema. However, long-term exposure to certain pollutants may increase the risk of developing respiratory diseases, including COPD, which encompasses emphysema.
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