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 B
Explanation
Choice A Reason:
Keeping lights turned to medium level in the evening is incorrect. This intervention is aimed at reducing environmental stimuli, which may be appropriate for some patients with neurological conditions to minimize sensory overload and promote rest. However, it is not a specific intervention for preventing cerebral aneurysm rupture.
Choice B Reason:
Maintaining the head of the bed between 30 and 45° is correct. Keeping the head of the bed elevated can help reduce intracranial pressure and decrease the risk of cerebral aneurysm rupture or rebleeding in patients with aneurysmal subarachnoid hemorrhage. This position promotes venous drainage from the brain and helps prevent increases in intracranial pressure.
Choice C Reason:
Administering hypotonic intravenous solutions is incorrect. Hypotonic intravenous solutions have a lower osmolarity than blood plasma and can lead to cerebral edema, which may exacerbate intracranial pressure and increase the risk of cerebral aneurysm rupture. Isotonic solutions, such as normal saline (0.9% NaCl) or lactated Ringer's solution, are typically preferred for fluid resuscitation and maintenance in patients at risk of cerebral aneurysm rupture.
Choice D Reason:
Reposition the client every shift is incorrect. Repositioning the client every shift helps prevent complications associated with immobility, such as pressure ulcers, pneumonia, and venous thromboembolism. While important for overall patient care, repositioning alone does not directly address the risk of cerebral aneurysm rupture.
Correct Answer is ["A","D","E"]
Explanation
Choice A Reason:
"Are you having any feelings of depression?". This statement is appropriate. Migraines can significantly impact mood, and depression is a common comorbidity in individuals with chronic migraines. Inquiring about feelings of depression allows the nurse to assess the client's mental health status and provide appropriate support or referrals if needed.
Choice B Reason:
"Are you experiencing any sensitivity to light?": This statement is inappropriate. This question addresses a physical symptom commonly associated with migraines rather than psychosocial impact.
Choice C Reason:
"Are you feeling any increase in your sexual drive?"Migraines are more likely to decrease sexual drive due to pain and fatigue. This question is not typically relevant to the psychosocial impact of migraines.
Choice D Reason:
"Are you experiencing any episodes of 'panic-type' feelings?" This statement is appropriate. Migraines can sometimes trigger anxiety or panic attacks in affected individuals. Inquiring about panic-type feelings allows the nurse to assess the client's emotional response to migraines and provide interventions or referrals for anxiety management if necessary.
Choice E Reason:
"Are you experiencing more fatigue as compared to before you had migraines?": This statement is appropriate. Fatigue is a common symptom associated with migraines, both during and after an attack. Assessing the client's level of fatigue helps the nurse understand the impact of migraines on the client's energy levels and overall functioning.
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