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 D
Explanation
Choice A rationale
Age is a non-modifiable risk factor for stroke. As people age, their risk of stroke increases. However, this is not something that can be changed or controlled.
Choice B rationale
Sickle cell disease is a genetic disorder that can increase the risk of stroke, particularly in children. However, it is not a modifiable risk factor because it is determined by the person’s genes.
Choice C rationale
Having a parent with cardiovascular disease can increase a person’s risk of stroke. However, this is a non-modifiable risk factor because it is determined by genetics.
Choice D rationale
Hypertension, or high blood pressure, is a major modifiable risk factor for stroke. It can be controlled through lifestyle changes and medication.
Correct Answer is ["A","D","F"]
Explanation
Choice A rationale
Patients with poorly controlled diabetes, such as those experiencing diabetic ketoacidosis (DKA), are at an increased risk of developing peripheral neuropathy. High blood sugar levels can damage peripheral nerves over time.
Choice B rationale
Sleep apnea is not typically associated with an increased risk of developing peripheral neuropathy.
Choice C rationale
While hypertension can lead to a variety of health complications, it is not typically associated with an increased risk of developing peripheral neuropathy.
Choice D rationale
Systemic Lupus Erythematosus (SLE) is an autoimmune disease that can affect the nervous system, including the peripheral nerves, leading to peripheral neuropathy.
Choice E rationale
Untreated tuberculosis is not typically associated with an increased risk of developing peripheral neuropathy.
Choice F rationale
Chronic alcohol use can lead to nutritional deficiencies, particularly of the B vitamins, which are essential for nerve health. This can result in peripheral neuropathy.
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