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

Pulse pressure is calculated as the difference between systolic and diastolic blood pressure. 170 - 90 = 80 mm Hg, so the pulse pressure would be 80mmHg.

A. the beginning of each shift. B. admission to the unit. C. discharge. D. the patient's wakening in the morning.

Correct Answer is A

Explanation

A. Performing a quick focused assessment at the beginning of each shift allows the nurse to identify any immediate needs or changes in the patient's condition, ensuring timely and appropriate care. This practice helps in maintaining continuity of care and promptly addressing any issues that may arise during the shift.
B. While a comprehensive assessment is typically performed upon admission to the unit, a quick focused assessment is not specifically required at this time. The initial comprehensive assessment will cover all necessary information.
C. At discharge, the focus is on providing discharge instructions and ensuring the patient understands their care plan after leaving the facility. A quick focused assessment is not typically performed at this time.
D. While it is important to check on the patient in the morning, a quick focused assessment is not specifically required at this time. The beginning of each shift is a more critical time to perform this assessment to ensure continuity of care.

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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

The nurse documents vital signs on a newly admitted patient as: "blood pressure is 170/90 mm Hg, the pulse is 80 beats/min, and the respirations are 16 breaths/min." The nurse would record the pulse pressure as:

Correct Answer is B

Explanation

It is the responsibility of the nurse to perform a quick focused assessment of the patient upon:

Correct Answer is A

Explanation

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