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. People who abstain from alcohol: Abstaining from alcohol does not necessarily increase the risk of sustaining a traumatic brain injury (TBI). In fact, excessive alcohol consumption can increase the risk of falls and accidents leading to TBIs, but abstaining from alcohol itself is not a risk factor for TBI.

B. People who live in rural areas: Living in rural areas may be associated with certain risk factors for TBIs, such as increased rates of motor vehicle accidents due to factors like higher speed limits and longer distances traveled. However, it is not a direct cause of TBIs.

C. People who play contact sports: Engaging in contact sports, such as football, soccer, or rugby, poses a higher risk of sustaining a traumatic brain injury due to the potential for collisions, falls, and impacts during gameplay.

D. People who are in their 30's: While traumatic brain injuries can occur at any age, individuals who are involved in activities with a higher risk of head injuries, such as contact sports or high-risk occupations, may be more prone to TBIs regardless of their age. Age alone is not a significant risk factor for TBIs.

A. "Your heart condition is caused by excessive stretching of the ventricles." B. "Your heart condition is caused from stiffening of the walls of the ventricles." C. "Your heart condition is caused by thickening of the ventricular walls and septum." D. "Your heart condition is caused when the ventricular tissue becomes fibrous and fatty."

Correct Answer is B

Explanation

A. "Your heart condition is caused by excessive stretching of the ventricles": This statement is incorrect. Excessive stretching of the ventricles typically occurs in dilated cardiomyopathy, not restrictive cardiomyopathy (RCM). In RCM, the primary issue is not excessive stretching but rather stiffening of the ventricular walls.

B. "Your heart condition is caused from stiffening of the walls of the ventricles": This statement is correct. Restrictive cardiomyopathy (RCM) is characterized by abnormal stiffening (fibrosis) of the ventricular walls, which impairs the heart's ability to fill properly during the diastolic phase of the cardiac cycle. This stiffening restricts the heart's ability to relax and fill with blood efficiently.

C. "Your heart condition is caused by thickening of the ventricular walls and septum": This statement describes hypertrophic cardiomyopathy (HCM), not restrictive cardiomyopathy (RCM). In HCM, there is abnormal thickening of the ventricular walls and septum, leading to impaired filling of the ventricles and potential obstruction of blood flow out of the heart.

D. "Your heart condition is caused when the ventricular tissue becomes fibrous and fatty": This statement describes arrhythmogenic right ventricular cardiomyopathy (ARVC), not restrictive cardiomyopathy (RCM). ARVC is characterized by replacement of myocardial tissue with fibrous and fatty tissue, primarily affecting the right ventricle.

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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 caring for a client who has a traumatic brain injury (TBI). Which of the following groups should the nurse understand has a higher risk of sustaining a TBI?

Correct Answer is C

Explanation

A nurse is teaching a client who has restrictive cardiomyopathy (RCM). Which of the following statements should the nurse include in the client teaching to explain the cause of RCM?

Correct Answer is B

Explanation

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