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","B","D"]
Explanation
Choice A Reason:
African American clients is appropriate. Research suggests that African Americans have a lower prevalence of MS compared to White Americans, but they tend to have more severe disease progression and higher disability rates when diagnosed with MS.
Choice B Reason:
White American clients: Individuals of European descent, including White Americans, have the highest prevalence of MS, particularly those of northern European ancestry. MS is more common in populations of northern European descent compared to other racial and ethnic groups.
Choice C Reason:
East Asian clients: East Asians, including individuals of Chinese, Japanese, and Korean descent, have historically had lower rates of MS compared to individuals of European descent. However, MS prevalence appears to be increasing in East Asian populations, possibly due to changes in lifestyle and environmental factors.
Choice D Reason:
Hispanic or Latino clients: Studies suggest that the prevalence of MS is lower in Hispanic/Latino populations compared to White Americans but higher than in African Americans. However, there is considerable variation in MS prevalence among different Hispanic/Latino subgroups.
Choice E Reason:
Navajo Indian clients: Native American populations, including Navajo Indians, have been reported to have a lower prevalence of MS compared to individuals of European descent. However, limited data are available on MS prevalence and incidence in specific Native American tribes, and more research is needed to fully understand the disease burden in these populations.
Correct Answer is ["A","B","C","D"]
Explanation
Choice A Reason:
Chronic cough is correct. Persistent cough is a common symptom of COPD, often occurring due to irritation and inflammation in the airways.
Choice B Reason:
Sputum production is correct. COPD patients frequently experience increased mucus production, leading to coughing up phlegm or sputum, especially in the morning.
Choice C Reason:
Dyspnea is correct. Shortness of breath or dyspnea is a hallmark symptom of COPD, particularly during physical activity or exertion, and it tends to worsen as the disease progresses.
Choice D Reason:
Wheezing occurs due to narrowed airways and increased airway resistance. It is more noticeable during expiration but can also be present during inspiration in severe cases.
Choice E Reason:
Chest tightness is incorrect. While chest tightness can occur in COPD, it is typically more associated with asthma. However, some individuals with COPD may experience chest tightness, especially during exacerbations or when airflow is significantly limited.
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