A nurse in the emergency department is evaluating a client who was brought in by a neighbor after suddenly falling while walking.
What assessments should the nurse prioritize?

Assessing muscle strength

Checking for facial symmetry

Checking peripheral pulses

Evaluating vision changes

Checking for aphasia

Asking about smoking history

Answer and Explanation

Correct Answer : A,B,D,E

Choice A rationale
Assessing muscle strength is important after a fall as it can help determine if the fall was due to muscle weakness or other neurological issues.
Choice B rationale
Checking for facial symmetry is crucial as asymmetry may indicate a stroke or other serious neurological condition.
Choice C rationale
While checking peripheral pulses is important in general, it may not be the top priority in this case unless there is a specific reason to suspect circulatory issues.
Choice D rationale
Evaluating vision changes is important as sudden vision loss or changes could indicate a serious condition such as a stroke.
Choice E rationale
Checking for aphasia, or difficulty with language, is crucial as it can be a sign of a stroke or other serious neurological condition.
Choice F rationale
Asking about smoking history may not be a priority in the immediate assessment of a patient who has just fallen.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is A

Explanation

Choice A rationale
Cushing’s Triad, which includes bradycardia (low heart rate), irregular respiration, and widened pulse pressure, is a nervous system response that could prevent brainstem ischemia. Brainstem ischemia is a condition where there is insufficient blood flow to the brainstem, which can lead to cell death.
Choice B rationale

While tachycardia (high heart rate) is a serious condition, it is not typically prevented by Cushing’s Triad.
Choice C rationale
Agonal breathing, which is characterized by gasping, labored breathing, particularly when lying flat, is not typically prevented by Cushing’s Triad.
Choice D rationale
Chest pain is not typically prevented by Cushing’s Triad. Cushing’s Triad is a response to increased intracranial pressure, not a cardiac condition.

A. Hyponatremia B. Paresthesia C. Foot drop D. Intermittent pain E. Hyperreflexia

Correct Answer is ["B","C","D"]

Explanation

Choice A rationale
Hyponatremia, or low sodium levels, is not typically a symptom of degenerative disc disease. It can be caused by a variety of conditions, but it is not directly linked to degenerative disc disease.
Choice B rationale
Paresthesia, or abnormal sensations such as tingling or prickling, can develop with degenerative disc disease. This is due to the fact that degenerative changes can lead to nerve compression, which can cause these sensations.
Choice C rationale
Foot drop, a gait abnormality, can be a symptom of degenerative disc disease. It can occur if the disease process affects the nerves that control the muscles involved in lifting the foot.
Choice D rationale
Intermittent pain is a common symptom of degenerative disc disease. The pain can vary in intensity and may be worse with certain activities or positions.
Choice E rationale
Hyperreflexia, or overactive reflexes, is not typically a symptom of degenerative disc disease. It is more commonly associated with conditions that affect the upper motor neurons.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A nurse in the emergency department is evaluating a client who was brought in by a neighbor after suddenly falling while walking. What assessments should the nurse prioritize?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is gathering neurological data on a patient with a neurological injury and observes signs indicative of Cushing’s Triad. The nurse understands that Cushing’s Triad is a nervous system response that could prevent which of the following conditions?

Correct Answer is A

Explanation

A nurse is caring for a client who has degenerative disc disease. Which of the following assessment findings should the nurse understand might develop with this condition? (Select All that Apply)

Correct Answer is ["B","C","D"]

Explanation

A nurse is educating a student about cerebral edema. The student nurse inquires, “What type of cerebral edema is associated with a patient who has had a stroke?” Which of the following is the best response from the nurse?

A nurse is providing care for a patient who is at risk of cerebral aneurysm rupture. Which of the following interventions should the nurse include in the care plan?

A nurse is caring for a client who has had a traumatic fall. Which of the following interventions should the nurse implement first?

A nurse is caring for a client admitted with meningitis. The student nurse asks, “I know that the client has a lot of edema in the brain, but what causes it?” Which of the following responses from the nurse best answers the student’s querry

A client with uncontrolled diabetes mellitus reports experiencing numbness and tingling in their feet that disrupts their sleep.The nurse explains this as a nerve disorder known as peripheral neuropathy. Which statement by the client indicates they understand the cause of this condition?

A nurse is caring for a 77-year-old African American male client in the emergency department. Exhibits Based on the clients progression. Which of the following actions should the nurse take? Select all that apply:

A nurse is giving discharge instructions to a client with epilepsy. What should be included in the nurse’s instructions?

A nurse in the emergency department is evaluating a client who was brought in by a neighbor after suddenly falling while walking. What assessments should the nurse prioritize?

A nurse in the emergency department is evaluating a client who was brought in by a neighbor after suddenly falling while walking.
What assessments should the nurse prioritize?