A nurse is preparing to conduct a fall risk screening on a client.
Which of the following variables will the nurse use to evaluate the client? (Select all that apply.)

Fall history.

Medical diagnosis.

Use of assistive devices.

Mental status.

Do-not-resuscitate status.

Answer and Explanation

Correct Answer : A

Choice A rationale:

Maintaining the patency of the client's airway is the priority action. During a seizure, the client may lose consciousness and have difficulty breathing. Ensuring a clear airway is essential to prevent hypoxia and maintain oxygenation. This can be achieved by positioning the client on her side and removing any obstructions from her mouth to allow for adequate airflow.

Choice B rationale:

Identifying the poison the client ingested is important for providing appropriate medical treatment, but it is not the priority action in this scenario. Airway management takes precedence because it addresses the immediate threat to the client's life.

Choice C rationale:

Measuring the client's blood pressure is a necessary assessment, but it is not the priority during an active seizure. Airway management and seizure control are the immediate concerns. Once the seizure is controlled and the airway is secured, other assessments, including blood pressure measurement, can be performed.

Choice D rationale:

Positioning the client on her side is a correct action, but it should be done after ensuring the patency of the airway. Placing the client on her side helps prevent aspiration in case of vomiting during or after the seizure. However, it is not the priority over ensuring the client can breathe properly.

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Correct Answer is B

Explanation

Choice A rationale:

Obtaining the blood pressure first thing in the morning is not the most critical factor in accurately measuring blood pressure. Blood pressure can vary throughout the day due to various factors, and it is essential to use the appropriate technique and equipment at any time of the day.

Choice B rationale:

Using the appropriate size cuff for the client is crucial in obtaining an accurate blood pressure reading. If the cuff is too small, it can lead to falsely elevated blood pressure readings, while a cuff that is too large can result in falsely lowered readings. This is because cuff size affects the pressure applied to the artery during measurement.

Choice C rationale:

Ensuring that the client is relaxed and comfortable prior to obtaining the blood pressure is important but not the most critical factor. Anxiety or discomfort can temporarily elevate blood pressure, so it's essential to create a calm and comfortable environment for the client. However, using the correct cuff size is still more critical for accurate measurements.

Choice D rationale:

Removing clothing from the arms before obtaining blood pressure is not the most important action. While it is generally recommended to expose the client's arm for proper cuff placement, it is secondary to using the appropriate cuff size. The cuff should be placed directly on the skin or over a thin layer of clothing, but this step should not take precedence over cuff size selection.

A. Superior. B. Medial. C. Ventral. D. Caudal.

Correct Answer is A

Explanation

Choice A rationale:

Superior means more toward the head or above another structure. In anatomical terms, superior refers to a structure being closer to the head or higher than another structure in the body. For example, the head is superior to the neck because it is above the neck.

Choice B rationale:

Medial refers to the middle or near the middle of the body. It is used to describe structures that are closer to the midline of the body. For example, the nose is medial to the eyes because it is closer to the midline of the face.

Choice C rationale:

Ventral refers to the front or belly side of the body. It is opposite to dorsal, which refers to the back side of the body. Ventral structures are those that are located on the front side of the body, like the chest and abdomen.

Choice D rationale:

Caudal means toward the tail or inferior end of the body. It is opposite to superior and refers to structures that are located below or toward the tail end of the body. For example, the feet are caudal to the head because they are below the head.

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A nurse is preparing to conduct a fall risk screening on a client.Which of the following variables will the nurse use to evaluate the client? (Select all that apply.)

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Naxlex Comprehensive Predictor Exams

To accurately take a client's blood pressure, which action by the nurse is most important?

Correct Answer is B

Explanation

Which directional term means more toward the head or above another structure?

Correct Answer is A

Explanation

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A nurse is preparing to conduct a fall risk screening on a client.Which of the following variables will the nurse use to evaluate the client? (Select all that apply.)

A nurse is preparing to conduct a fall risk screening on a client.
Which of the following variables will the nurse use to evaluate the client? (Select all that apply.)