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. Consume foods high in potassium: Potassium deficiency can contribute to certain health issues, but it is not directly linked to hearing loss. However, maintaining a balanced diet rich in nutrients, including potassium, is important for overall health.

B. Increase oral intake of water: Hydration is essential for overall health, but increasing oral intake of water is not specifically associated with decreasing the risk of hearing loss. While staying hydrated is beneficial for various bodily functions, including maintaining proper ear function, it is not a direct preventive measure for hearing loss.

C. Avoid smoking tobacco products: Smoking tobacco products is a significant risk factor for developing hearing loss. Smoking can damage blood vessels and reduce blood flow to the inner ear, leading to hearing impairment. Therefore, advising clients to avoid smoking or quit smoking is an important lifestyle modification to decrease the risk of hearing loss.

D. Limit alcohol to two drinks daily: Excessive alcohol consumption can have detrimental effects on hearing health, including increasing the risk of hearing loss and vestibular dysfunction. Therefore, limiting alcohol intake is recommended to reduce the risk of developing hearing-related problems.

A. Encouraging increased mobility B. Dietary and fluid restrictions C. Cessation of intravenous (IV) drug use D. Cessation of hormonal supplements

Correct Answer is B

Explanation

A. Encouraging increased mobility: While mobility is important for overall health, it may not be the primary lifestyle modification emphasized in the discharge teaching for heart failure. The focus is typically on dietary and fluid restrictions, medication adherence, and symptom management.

B. Dietary and fluid restrictions: Dietary and fluid restrictions are essential lifestyle modifications for managing heart failure. Clients are often advised to follow a low-sodium diet and restrict fluid intake to prevent fluid retention and exacerbation of heart failure symptoms.

C. Cessation of intravenous (IV) drug use: While cessation of intravenous drug use is important for overall health and may be addressed if relevant to the client's situation, it may not be a primary focus of discharge teaching specifically related to heart failure.

D. Cessation of hormonal supplements: Cessation of hormonal supplements may be recommended if they contribute to heart failure or exacerbate its symptoms. However, this recommendation would be specific to individual client circumstances and may not apply to all clients with heart failure.

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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

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