Exhibits
The nurse inspects the airway. There is no visible trauma, and the airway appears to be patent. What other assessment items are included in the primary survey? Select all that apply.
A Allergies
B Circulation
C Neurological status
D Ventilation
E Current medications
F Exposure
Correct Answer : B,D,E
A. Allergies
Allergies are important to know but are not part of the primary survey. The primary survey focuses on immediate life threats, such as airway, breathing, and circulation, rather than detailed background information.
B. Circulation
Assessment of circulation is critical in the primary survey to identify and manage life-threatening conditions such as shock or severe bleeding. It includes evaluating blood pressure, heart rate, and peripheral pulses to assess the effectiveness of the cardiovascular system.
C. Neurological status
While neurological status is important, it is part of a secondary survey rather than the primary survey. The primary survey focuses on immediate life-threatening conditions, while the neurological status is assessed more thoroughly in the secondary survey.
D. Ventilation
Assessing ventilation is a crucial part of the primary survey. This involves checking the client's breathing rate, depth, and effectiveness to ensure adequate oxygenation and addressing any immediate respiratory distress.
E. Current medications
Knowing current medications is important for overall care but is not part of the primary survey. The primary survey addresses life-threatening conditions rather than details of medication history.
F. Exposure
Exposure is part of the primary survey, ensuring that the client is completely exposed for a thorough assessment while protecting their privacy and warmth. It involves checking for hidden injuries and ensuring the client’s environment is safe.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Sickle cell anemia typically presents with hemolytic crises and sickle-shaped red blood cells, not necessarily heavy menstrual bleeding.
B. Folic acid deficiency anemia can cause macrocytic anemia but is less likely to cause heavy menstrual bleeding as the primary symptom.
C. Pernicious anemia is due to vitamin B12 deficiency and typically presents with neurological symptoms along with anemia, not necessarily heavy menstrual bleeding.
D. Iron-deficiency anemia commonly presents with weakness, fatigue, and heavy menstrual bleeding due to inadequate iron for red blood cell production.
Correct Answer is D
Explanation
A. Dismissing the client's feelings does not address the client's anxiety.
B. Comparing the client to others does not address her individual concerns and may feel dismissive.
C. Asking "why" questions can come across as judgmental and may not encourage open communication.
D. Encouraging the client to express her concerns is a therapeutic communication technique that validates her feelings and can help reduce anxiety.
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