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A patient was admitted with possible head trauma after a motor vehicle accident. The nursing implementation with the highest priority is to:

A.

auscultate lung and abdominal sounds.

B.

check for verbal and motor response.

C.

monitor daily weight.

D.

monitor intake and output.

Answer and Explanation

The Correct Answer is B

A.    While auscultating lung and abdominal sounds is important, it is not as urgent as checking neurological function in a head trauma patient.
B.    Assessing verbal and motor responses is critical to evaluate the level of consciousness and neurological function in a patient with head trauma.
C.    Monitoring daily weight is not an immediate concern for a patient with possible head trauma.
D.    Monitoring intake and output is important but not the priority compared to assessing the neurological status in head trauma patients.
 


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Related Questions

Correct Answer is D

Explanation

A. A murmur or swishing sound does not correspond to the diastolic pressure; it is more indicative of turbulent blood flow.
B. Clear tapping sounds are heard at systolic pressure but do not indicate diastolic pressure.
C. Knocking sounds are associated with systolic pressure, not diastolic.
D. The muffling sound heard after the first Korotkoff sounds indicates the diastolic pressure in children and some adults, which is the correct method for assessing the diastolic reading.

Correct Answer is A

Explanation

A. This is because the patient's blood pressure of 98/66 mm Hg, while on the lower side, may be normal for them. It's important to compare it to their baseline to determine if there has been a significant change.
B. The blood pressure is within a normal range for an adult, so immediate notification of hypotension is not required.
C. This can be done after determining if there is a significant change from the baseline.
D. The pulse is not bradycardic (it is within a normal range), so there is no immediate need to notify the doctor regarding bradycardia.

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