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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
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.
Correct Answer is D
Explanation
A. Temperature monitoring is important but not a top priority when a patient is receiving opiates unless there is suspicion of infection.
B. Pulse monitoring is also important but does not immediately indicate issues with opiate use.
C. Blood pressure is influenced by opiate use, but the primary concern is respiratory function due to the risk of respiratory depression.
D. Respirations should be closely monitored because opiates can significantly depress the respiratory system, leading to hypoventilation or respiratory arrest, which is the most critical risk.
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