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
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
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
The aura phase is characterized by sensory, motor, or visual disturbances that occur before the headache phase of a migraine. Symptoms such as tingling of the face and blind spots in the eyes are common during this phase.
Choice B rationale
The postdrome phase, also known as the “migraine hangover,” occurs after the headache phase. It does not typically include symptoms such as tingling of the face or blind spots in the eyes.
Choice C rationale
The prodrome phase, also known as the pre-headache phase, can occur hours to days before the headache phase. It can include symptoms such as mood changes, food cravings, and neck stiffness, but not typically tingling of the face or blind spots in the eyes.
Choice D rationale
The headache phase is the period during a migraine when the actual headache occurs. It is not typically associated with symptoms such as tingling of the face or blind spots in the eyes.
Correct Answer is B
Explanation
Choice A rationale
Maintaining systolic BP between 141 and 145 mm Hg is considered high and can increase the risk of stroke.
Choice B rationale
The client should maintain systolic BP between 120 and 129 mm Hg. This is considered a normal blood pressure range and can help reduce the risk of stroke.
Choice C rationale
Maintaining systolic BP between 130 and 135 mm Hg is considered elevated and can increase the risk of stroke.
Choice D rationale
Maintaining systolic BP between 136 and 140 mm Hg is considered high and can increase the risk of stroke.
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