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 D

Explanation

A. A score of 7 would indicate a much lower level of consciousness and require urgent intervention.
B. A score of 12 would indicate some level of impairment, with the patient not fully alert or responsive.
C. A score of 10 would indicate some level of impairment, with the patient not fully alert or responsive.
D. A score of 15 on the Glasgow Coma Scale indicates full consciousness and normal neurological function. It is the highest possible score, reflecting a patient who is awake, aware, and able to follow commands.

A. After palpating the abdomen B. Prior to percussing the abdomen C. After checking for kidney tenderness D. Prior to inspecting the abdomen

Correct Answer is B

Explanation

A. Palpation may alter bowel sounds, making auscultation after palpation less accurate.
B. Auscultation should be performed before percussion or palpation to prevent interference with the sounds.
C. Checking for kidney tenderness is important but does not affect the timing of auscultating bowel sounds.
D. Inspection should be done before auscultation to assess for any obvious abnormalities before listening for bowel sounds.

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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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Correct Answer is D

Explanation

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Correct Answer is B

Explanation

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