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 ["B","D"]
Explanation
Choice A rationale
Oxycodone is an opioid medication, not a nonopioid analgesic. It is used for the relief of moderate to severe pain but has a high potential for addiction and dependence.
Choice B rationale
Ibuprofen is a nonopioid analgesic. It belongs to a class of drugs known as nonsteroidal anti- inflammatory drugs (NSAIDs) and is commonly used to relieve pain, reduce inflammation, and lower fever.
Choice C rationale
Fentanyl is a potent opioid pain medication. It is not a nonopioid analgesic. It is used for managing severe pain, often in people who have built up a resistance to other opioids.
Choice D rationale
Acetaminophen is a nonopioid analgesic. It is used to relieve mild to moderate pain from headaches, muscle aches, menstrual periods, colds and sore throats, toothaches, backaches, and reactions to vaccinations, and to reduce fever.
Correct Answer is B
Explanation
Choice A rationale
Reducing the temperature in the room is not typically a treatment for brain herniation. While it’s important to maintain a comfortable environment for the patient, there’s no evidence to suggest that room temperature has a direct impact on the progression or treatment of brain herniation.
Choice B rationale
Hyperventilating the patient is a possible treatment for brain herniation. Hyperventilation causes vasoconstriction, which can decrease cerebral blood flow and intracranial pressure, potentially relieving the pressure caused by the herniation.
Choice C rationale
Lowering blood pressure is not typically a treatment for brain herniation. While maintaining a stable blood pressure is important in all patients, aggressively lowering blood pressure could potentially decrease cerebral perfusion and worsen the patient’s condition.
Choice D rationale
Decreasing sedation is not typically a treatment for brain herniation. In fact, sedatives might be used to reduce metabolic demands and control agitation in a patient with brain herniation.
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