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 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.
Correct Answer is D
Explanation
Choice A Reason:
Glatiramer acetate is incorrect because it is used in the treatment of multiple sclerosis (MS) to reduce the frequency of relapses and delay disease progression. It is not indicated for spasm-induced incontinence.
Choice B Reason:
Dulaglutide is incorrect because it is a medication used to treat type 2 diabetes by improving blood sugar control. It is not indicated for the treatment of spasm-induced incontinence.
Choice C Reason:
Montelukast sodium is incorrect because it is a leukotriene receptor antagonist primarily used to manage asthma and allergic rhinitis. It is not indicated for the treatment of spasm-induced incontinence.
Choice D Reason:
Oxybutynin is an anticholinergic medication commonly used to treat overactive bladder and urinary incontinence, including spasm-induced incontinence that can occur in individuals with spinal cord injury. It works by relaxing the smooth muscles of the bladder, thereby reducing involuntary contractions that contribute to urinary urgency and incontinence.
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