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 D

Explanation

A. A client who has coronary artery disease (CAD) and Bell's palsy: Bell's palsy, a condition characterized by sudden, temporary weakness or paralysis of the facial muscles, does not directly increase the risk of complications following CABG surgery. While Bell's palsy may affect facial muscle function, it typically does not impact respiratory function or cardiovascular stability during surgery.

B. A client who has coronary artery disease (CAD) and chronic diverticulitis: Chronic diverticulitis, inflammation or infection of the diverticula in the colon, is not directly related to increased risk for complications following CABG surgery. While diverticulitis may require medical management and dietary modifications, it does not typically affect cardiovascular or respiratory function during surgery.

C. A client who has coronary artery disease (CAD) and chronic allergies: Chronic allergies, while they may cause respiratory symptoms such as nasal congestion or rhinitis, are not typically associated with increased risk for complications following CABG surgery. Allergies alone are unlikely to significantly impact cardiovascular stability or respiratory function during surgery compared to conditions such as COPD.

D. A client who has coronary artery disease (CAD) and chronic obstructive pulmonary disease (COPD): A client with CAD and COPD is at the highest risk for complications following coronary artery bypass graft (CABG) surgery. COPD is a chronic respiratory condition characterized by airflow limitation and increased airway resistance, often accompanied by emphysema and chronic bronchitis. These respiratory impairments can significantly impact the client's ability to tolerate anesthesia, mechanical ventilation, and postoperative respiratory function. COPD increases the risk of complications such as atelectasis, pneumonia, exacerbation of COPD, and respiratory failure following CABG surgery.

A. Diminished hair growth on the lower extremities B. Loss of pigmentation over the shin area C. Shiny appearance to the lower extremities D. Swollen and enlarged veins

Correct Answer is D

Explanation

A. Diminished hair growth on the lower extremities: Diminished hair growth on the lower extremities is not typically a manifestation of peripheral venous disease. Instead, it may suggest poor circulation or arterial insufficiency.

B. Loss of pigmentation over the shin area: Loss of pigmentation over the shin area can occur in conditions such as chronic venous insufficiency, which is a form of peripheral venous disease. However, it is not the most characteristic manifestation.

C. Shiny appearance to the lower extremities: A shiny appearance to the lower extremities is often associated with arterial insufficiency rather than peripheral venous disease. It can indicate thinning of the skin due to poor circulation and oxygenation.

D. Swollen and enlarged veins: Swollen and enlarged veins, also known as varicose veins, are classic manifestations of peripheral venous disease. These veins result from venous insufficiency, which leads to blood pooling and increased pressure in the veins, causing them to dilate and become visibly enlarged.

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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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Explanation

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