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

Answer and Explanation

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.

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Correct Answer is C

Explanation

A. Tau protein: Tau protein is primarily associated with Alzheimer's disease and other tauopathies, not Lewy body dementia.

B. Neurofibrillary tangles: Neurofibrillary tangles are aggregates of hyperphosphorylated tau protein found in Alzheimer's disease, not typically in Lewy body dementia.

C. Alpha-synuclein protein: Lewy bodies, which are abnormal aggregates of alpha-synuclein protein, are a hallmark pathology of Lewy body dementia. These protein aggregates disrupt neuronal function and are responsible for the cognitive, motor, and emotional symptoms seen in Lewy body dementia.

D. Beta-amyloid protein: Beta-amyloid protein is primarily associated with Alzheimer's disease, not Lewy body dementia. It forms plaques in the brain, which contribute to neurodegeneration and cognitive decline in Alzheimer's disease.

A. Decreased circulation to the kidneys B. Increased mental capacity C. Improving respiratory function D. Improvement in heart rate and blood pressure

Correct Answer is A

Explanation

A. Decreased circulation to the kidneys: Post-cardiac arrest syndrome (PCAS) is a constellation of systemic ischemia/reperfusion injury responses that occur after return of spontaneous circulation (ROSC) following cardiac arrest. One of the manifestations of PCAS is decreased circulation to the kidneys due to the systemic hypoperfusion that occurs during cardiac arrest and the subsequent reperfusion injury that follows ROSC. This can lead to acute kidney injury (AKI) in some cases.

B. Increased mental capacity: While it is crucial to monitor neurological status after cardiac arrest, an immediate increase in mental capacity is not typically indicative of PCAS. Rather, neurological assessment may involve evaluating for signs of brain injury or dysfunction, which can include altered mental status, confusion, or neurological deficits.

C. Improving respiratory function: Improvement in respiratory function after cardiac arrest is a positive sign but may not necessarily indicate the development of PCAS. PCAS primarily involves systemic responses to the ischemia/reperfusion injury that occurs during and after cardiac arrest, rather than isolated respiratory changes.

D. Improvement in heart rate and blood pressure: Improvement in heart rate and blood pressure after cardiac arrest is generally expected with successful resuscitation efforts. However, these improvements alone may not necessarily indicate the development of PCAS. PCAS involves a broader range of systemic responses beyond just cardiac and hemodynamic changes.

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A nurse is caring for a client who has had a traumatic fall. Which of the following interventions should the nurse implement first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who has Lewy body dementia. The nurse should recognize that which of the following is responsible for changes in thinking, communication, movement, and emotional processing in Lewy body dementia?

Correct Answer is C

Explanation

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Correct Answer is A

Explanation

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