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.

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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Correct Answer is B

Explanation

A. Kussmaul's respirations are rapid, deep, and labored breaths often seen in metabolic acidosis, which does not match the pattern described.
B. Cheyne-Stokes respirations are characterized by a pattern of deep and fast breathing followed by periods of apnea. This pattern is seen in patients with severe conditions like heart failure or brain injury.
C. Biot's respirations are irregular, but the cycle does not have a distinct pattern of fast, slow, and apnea periods.
D. Hyperventilation refers to an increased rate of breathing but does not involve the cycles of deep, slow, and apneic phases characteristic of Cheyne-Stokes.

A. "When I shine a light into the patient's eyes, the pupils should constrict." B. "It is normal for the pupils to react sluggishly to light." C. "When I shine a light into the patient's eyes, the pupils should dilate D. "Pupil checks should be performed with the room lights on."

Correct Answer is A

Explanation

A. The normal response to light in the eye is pupil constriction. This indicates that the optic and oculomotor nerves are functioning properly.
B. While a sluggish reaction can occur in some individuals, a noticeable sluggish response could indicate neurological issues, especially in a head injury.
C. Pupils should constrict in response to light, not dilate, unless there is a significant neurological impairment.
D. Pupil checks should ideally be performed in dim lighting for better visibility of pupillary reactions, not with the room lights on.

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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:

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Naxlex Comprehensive Predictor Exams

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