A patient was admitted with possible head trauma after a motor vehicle accident. The nursing implementation with the highest priority is to:
auscultate lung and abdominal sounds.
check for verbal and motor response.
monitor daily weight.
monitor intake and output.
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 C
Explanation
A. While pupil response can be an indicator of consciousness, the primary concern when assessing pupils is to check for signs of increased intracranial pressure, such as unequal pupil size.
B. The shape of the pupil is important to assess, but the concern here is typically more about the size and response to light, which can indicate a neurological issue.
C. Unequal pupil sizes (anisocoria) can indicate neurological problems, such as increased intracranial pressure or brain injury, and requires further evaluation.
D. Pupil size changes could indicate a variety of issues, but the focus should be on detecting unequal pupils, which can be a critical sign in head injury patients.
Correct Answer is D
Explanation
A. Hyperthermia refers to an abnormally high body temperature due to external factors or failure to regulate body heat, not necessarily a fever coming down.
B. Pyrexia is another term for fever and occurs when the body temperature is elevated due to an infection or other causes.
C. Hypothermia refers to dangerously low body temperature, which is not related to a fever resolving.
D. Defervescence refers to the process of a fever breaking, and the body temperature returning to normal as the fever resolves.
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