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","B","D","E"]
Explanation
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.
Correct Answer is C
Explanation
Choice A rationale
Nicardipine is a calcium channel blocker used to treat high blood pressure. While it can be used in the management of subarachnoid hemorrhage, it is not primarily used to decrease intracranial pressure.
Choice B rationale
Dopamine is a type of medication used to treat certain conditions such as low blood pressure, heart failure, and Parkinson’s disease. It is not typically used to decrease intracranial pressure in the context of a subarachnoid hemorrhage.
Choice C rationale
Mannitol is a type of medication that is used to decrease intracranial pressure. It works by drawing fluid out of the brain to help reduce swelling.
Choice D rationale
Phenytoin is a medication used to control seizures. While it can be used in the management of subarachnoid hemorrhage, it is not primarily used to decrease intracranial pressure. Migraine Explore
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