A nurse is caring for a client who has had a traumatic fall. Which of the following interventions should the nurse implement first?
Administer acetaminophen by mouth for pain control
Perform a thorough health history
Prepare for a STAT non-contrast CT scan
Insert an indwelling urinary catheter to monitor urine output
The Correct Answer is C
A. Administer acetaminophen by mouth for pain control: While pain management is important, it is not the priority intervention in this situation. Administering acetaminophen for pain control can be done after the client's condition has been assessed and any potential serious injuries, such as head trauma, have been addressed.
B. Perform a thorough health history: Obtaining a health history is essential for understanding the client's baseline health status and any pre-existing conditions that may affect their current condition. However, in the acute phase following a traumatic fall, the priority is to assess and manage any potential life-threatening injuries.
C. Prepare for a STAT non-contrast CT scan: This is the correct answer. In cases of traumatic falls, particularly when there is concern for head injury or intracranial bleeding, obtaining a non-contrast CT scan of the head is a priority. This imaging study helps identify any intracranial injuries such as hemorrhage or skull fractures, allowing for prompt intervention if necessary.
D. Insert an indwelling urinary catheter to monitor urine output: Monitoring urine output is important for assessing renal function, but it is not the priority intervention in the immediate aftermath of a traumatic fall. The focus initially should be on assessing and managing potential life-threatening injuries, particularly those related to head trauma.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. White blood cell level of 5,900 mm3: While abnormal white blood cell levels can indicate infection or inflammation, they are not typically associated with directly contributing to an episode of delirium. However, underlying conditions that cause abnormal white blood cell levels, such as infection or inflammation, may contribute to delirium.
B. Potassium level of 4.1 mEq/L: Potassium imbalances can lead to various neurological symptoms, including weakness, paralysis, and cardiac arrhythmias. However, a potassium level of 4.1 mEq/L is within the normal range and is unlikely to directly contribute to an episode of delirium.
C. Hemoglobin level of 14.2 g/dL: Hemoglobin levels reflect the oxygen-carrying capacity of the blood and are not directly associated with delirium. While severe anemia or hypoxia can cause neurological symptoms, a hemoglobin level of 14.2 g/dL is within the normal range and is unlikely to directly contribute to delirium.
D. Blood glucose level of 254 mg/dL: Elevated blood glucose levels, as indicated by a blood glucose level of 254 mg/dL, can contribute to an episode of delirium. Hyperglycemia can lead to alterations in cerebral metabolism, neuronal dysfunction, and impaired cognitive function, predisposing individuals to delirium. Additionally, hyperglycemia can exacerbate preexisting neurological conditions and increase the risk of developing delirium in critically ill patients. Therefore, monitoring and managing blood glucose levels are essential in preventing and managing delirium in hospitalized patients.
Correct Answer is ["A","B","C","D","E"]
Explanation
A. Weight loss:
Weight loss can occur in individuals with dementia due to various factors, including decreased appetite, difficulty eating or swallowing, and increased energy expenditure.
Monitoring weight regularly can help detect changes in nutritional status and identify potential health concerns, such as malnutrition or dehydration.
B. Decreased mobility:
Individuals with dementia may experience a decline in mobility and functional abilities as the disease progresses.
Monitoring changes in mobility, such as difficulty walking, transferring, or performing activities of daily living, is important for assessing functional decline and implementing appropriate interventions to maintain mobility and prevent complications such as falls.
C. Increased physical activity:
While dementia can lead to decreased physical activity in some individuals, others may exhibit increased restlessness or wandering behaviors.
Monitoring changes in physical activity levels can help identify agitation, restlessness, or wandering behaviors that may require intervention to ensure the safety and well-being of the individual with dementia.
D. Unkempt appearance:
Individuals with dementia may neglect personal hygiene and grooming tasks, leading to an unkempt appearance.
Monitoring changes in appearance, such as poor personal hygiene, disheveled clothing, or neglect of grooming habits, can indicate difficulties with self-care and may necessitate assistance or supervision to maintain hygiene and appearance.
E. Constipation:
Constipation is a common gastrointestinal symptom in individuals with dementia, often due to factors such as reduced fluid intake, decreased physical activity, and side effects of medications.
Monitoring bowel habits and addressing constipation promptly can help prevent discomfort, complications such as fecal impaction, and maintain overall gastrointestinal health in individuals with dementia.
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