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 B

Explanation

A. Persistent headache and aggression: While persistent headache and aggression can occur following a traumatic brain injury (TBI), these symptoms are not specific to mild TBI. Aggression is more commonly associated with severe TBI, and persistent headache can occur across the spectrum of TBI severity.

B. Headache and confusion: Headache and confusion are common manifestations of mild TBI. Following a mild TBI, individuals often experience headache, which may be mild to moderate in intensity. Confusion, disorientation, and difficulty concentrating are also typical symptoms of mild TBI due to the transient disruption of cognitive function.

C. Loss of vision and depression: Loss of vision and depression are less commonly associated with mild TBI. These manifestations may occur in more severe cases of TBI or with specific types of brain injury affecting visual pathways. However, they are not typically indicative of mild TBI.

D. Seizures and extremity weakness: Seizures and extremity weakness are more indicative of moderate to severe TBI rather than mild TBI. While mild TBI may result in brief loss of consciousness, seizures and significant extremity weakness are less characteristic of mild TBI and are more commonly observed with more severe brain injuries.

A. Elevated erythrocyte sedimentation rate (ESR) B. Increased C-reactive protein (CRP) C. Elevated thyroid-stimulating hormone (TSH) D. Increased brain natriuretic peptide (BNP) E. Increased troponin I

Correct Answer is ["A","B","D","E"]

Explanation

A. Elevated erythrocyte sedimentation rate (ESR): Elevated ESR is commonly seen in inflammatory conditions such as pericarditis. ESR measures the rate at which red blood cells settle in a tube of blood over a certain period, and elevated levels indicate inflammation or tissue damage.

B. Increased C-reactive protein (CRP): CRP is an acute-phase reactant produced by the liver in response to inflammation. Elevated CRP levels are indicative of inflammation, making it a useful marker in pericarditis.

C. Elevated thyroid-stimulating hormone (TSH): Elevated TSH levels are not typically associated with pericarditis. TSH is a hormone produced by the pituitary gland that stimulates the thyroid gland to produce thyroid hormones. Elevated TSH levels are seen in conditions such as hypothyroidism.

D. Increased brain natriuretic peptide (BNP): BNP is a hormone produced by the heart in response to increased pressure and volume overload. Pericarditis can lead to increased pressure within the heart, resulting in elevated BNP levels. Therefore, increased BNP levels are anticipated in pericarditis.

E. Increased troponin I: Troponin I is a cardiac biomarker released into the bloodstream when there is damage to cardiac muscle cells. While pericarditis primarily involves inflammation of the pericardium (the sac surrounding the heart), severe cases can lead to myocardial involvement and subsequent release of troponin I. Therefore, increased troponin I levels may be observed in pericarditis, especially if there is myocardial involvement.

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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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Correct Answer is B

Explanation

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Correct Answer is ["A","B","D","E"]

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