A nurse is conducting a primary survey of a client who has sustained life-threatening injuries due to a motor-vehicle crash. Identify the sequence of actions the nurse should take.
(Move the actions into the box on the right, placing them in the selected order of performance. Use all the steps.)
Determine effectiveness of ventilator efforts.
Remove clothing for a thorough assessment.
Open the airway using a jaw-thrust maneuver.
Perform a Glasgow Coma Scale assessment.
Control any external bleeding.
The Correct Answer is C,A,D,B,E
The correct order is C,A,D,B,E.
C. Open the airway using a jaw-thrust maneuver.
This is the first priority since maintaining a clear airway is critical for the client’s survival.
A. Determine effectiveness of ventilatory efforts.
After ensuring the airway is open, assess the client’s breathing and whether they are ventilating effectively.
D. Perform a Glasgow Coma Scale assessment.
This step evaluates the client’s neurological status to determine their level of consciousness and identify any brain injuries.
B. Remove clothing for a thorough assessment.
To expose the client for a comprehensive physical examination and assess any injuries.
E. Control any external bleeding.
As part of circulation management, identify and stop any significant bleeding to prevent shock. This step addresses the "C" in ABCDE.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Medical insurance availability for substance use disorder treatment may affect an individual's ability to access treatment, but it does not directly increase the potential for addiction.
B. Exposure to substances during brain development can alter the structure and function of the brain, making it more susceptible to addiction later in life.
C. While cognitive deficits may contribute to addiction, they are not necessarily a factor that increases the potential for addiction.
D. The age at which an individual begins using substances may affect their risk of addiction, but it is not necessarily a factor that increases the potential for addiction.
Correct Answer is A
Explanation
A. This is important information to include, as schizophrenia is a chronic condition that often requires ongoing support and resources.
B. Schizophrenia is typically diagnosed in late adolescence or early adulthood, not after 40 years of age.
C. Co-occurring mental health conditions, such as depression or anxiety, are common in individuals with schizophrenia.
D. While individuals with schizophrenia may have a reduced life expectancy, it is not typically as low as 50.2 years of age.
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