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.
Neurological status
Circulation
Current medications
Allergies
Exposure
Ventilation
Correct Answer : A,B,E
A. Neurological status: Assessing the neurological status is crucial in the primary survey to
determine the client's level of consciousness, pupil reactions, and response to stimuli. This helps in identifying any potential brain injury or neurological deficits resulting from the fall.
B. Circulation: Evaluating circulation involves assessing the client's heart rate, blood pressure, and peripheral perfusion. In this scenario, the client's heart rate and blood pressure are provided in the nurse's notes, indicating the need to assess circulation as part of the primary survey.
C. Current medications: While important for the overall assessment and care of the client, assessing current medications is typically part of the secondary survey rather than the primary survey. The primary survey focuses on immediate life-threatening conditions.
D. Allergies: While allergies are essential information for the client's overall care, they are typically addressed during the secondary survey or during the history-taking process rather than as part of the primary survey.
E. Exposure: Assessing exposure involves ensuring the client is adequately covered and protected from environmental factors, especially in trauma situations where there may be significant blood loss or risk of hypothermia. This includes removing clothing to assess for additional injuries or bleeding.
F. Ventilation: While ventilation is crucial for assessing the client's respiratory status, including respiratory rate and effort, it is typically part of the primary survey rather than the primary survey itself. Assessing ventilation helps determine if the client is adequately breathing and oxygenating.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Compare muscle strength bilaterally. While hyperkalemia can lead to muscle weakness, assessing muscle strength bilaterally is not the most critical intervention in this scenario. The priority is to assess for cardiac manifestations of hyperkalemia.
B. Determine apical pulse rate and rhythm. Hyperkalemia can cause life-threatening cardiac dysrhythmias, including bradycardia, heart block, and ventricular tachycardia. Assessing the apical pulse rate and rhythm can provide essential information about cardiac function and help identify potential dysrhythmias.
C. Assess strength of deep tendon reflexes. Hyperkalemia can affect neuromuscular function, leading to hyperreflexia or diminished reflexes. While assessing deep tendon reflexes is
important, it is not as critical as assessing cardiac function in a client with known hyperkalemia.
D. Observe color and amount of urine. While changes in urinary output and characteristics may indicate renal impairment associated with hyperkalemia, the priority in this situation is to assess for cardiac manifestations of hyperkalemia.
Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"E"}
Explanation
A. Functional Improvement: This is crucial to assess because it indicates the effectiveness of the interventions implemented, such as physical and occupational therapy, and the overall progress of the client in regaining independence in activities of daily living. Tracking functional improvements helps determine if the client's physical abilities, mobility, and self- care skills are improving over time, which is essential for their overall well-being and quality of life.
B. Psychological Assessment: This aspect is important to evaluate because it helps gauge the client's mental and emotional well-being. Elderly individuals who are subjected to neglect or mistreatment, as in this case, may experience psychological distress, such as depression, anxiety, or feelings of helplessness. Monitoring the client's psychological status allows the nurse to identify any signs of emotional distress or trauma resulting from their situation, enabling appropriate interventions to support their mental health and emotional stability.
Additionally, assessing the caregiver's psychological well-being is also crucial as they may experience stress, burnout, or emotional strain from the caregiving responsibilities, which can impact the quality of care provided to the client.
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