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.
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Related Questions
Correct Answer is D
Explanation
Choice A rationale
While a CT angiogram can indeed reveal fractures within the skull or spine, this is not its primary purpose in the context of a subarachnoid hemorrhage. The main goal is to visualize the blood vessels in the brain.
Choice B rationale
A CT angiogram does not primarily reveal overproduction of cerebrospinal fluid (CSF). It is used to visualize the blood vessels in the brain.
Choice C rationale
While a CT angiogram can show areas of edema within the brain tissue, this is not its main purpose in the context of a subarachnoid hemorrhage. The primary goal is to visualize the blood vessels in the brain.
Choice D rationale
A CT angiogram can indeed reveal decreased blood flow related to vasospasm in the context of a subarachnoid hemorrhage. Vasospasm is a condition in which blood vessels spasm, leading to vasoconstriction. This can reduce blood flow to the brain, which can be visualized on a CT angiogram.
Correct Answer is B
Explanation
Choice A rationale
A patient reporting a burning sensation is a subjective sign of pain. It relies on the patient’s personal experience and verbal report.
Choice B rationale
A patient grimacing when they move is an objective sign of pain. It is observable and does not rely on the patient’s verbal report.
Choice C rationale
A patient rating their pain as an 8 on a scale of 0 to 10 is a subjective sign of pain. It relies on the patient’s personal experience and verbal report.
Choice D rationale
A patient stating the pain is located in their abdomen is a subjective sign of pain. It relies on the patient’s personal experience and verbal report.
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