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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

Answer and Explanation

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.

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Correct Answer is C

Explanation

A. Cover client with cooling blanket.
This could help manage the fever but is not the highest priority in the context of acute adrenal crisis.

B. Obtain an analgesic prescription.
Pain management is important, but it is not the immediate priority in a life-threatening adrenal crisis.

C. Infuse an intravenous fluid bolus.
This is the correct answer because the client is experiencing hypotension (low blood pressure), which is critical in an acute adrenal crisis. IV fluids are essential to restore blood pressure and perfusion.

D. Administer PRN oral antipyretic.
Managing the fever is important, but not the first priority. The client’s hemodynamic instability needs to be addressed immediately.

A. Bruising of the skin. B. Low-grade fever. C. Abdominal cramping. D. Bloody emesis.

Correct Answer is D

Explanation

A. Bruising of the skin is not typically associated with acute gastritis caused by contaminated water. While bruising may be a sign of other medical conditions or complications, it is not directly related to gastritis.

B. Low-grade fever can be a symptom of gastritis, especially if it is caused by an infectious agent. However, it is not typically a severe or emergent symptom that requires immediate reporting unless it is accompanied by other concerning symptoms.

C. Abdominal cramping is a common symptom of gastritis and may occur due to inflammation of the stomach lining. While it should be monitored, it is not as concerning as the potential complication indicated by option D.

D. Bloody emesis (vomiting blood) is a serious symptom that can indicate severe gastritis or complications such as gastrointestinal bleeding. It is essential to report this symptom promptly as it may require immediate medical attention and intervention.

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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.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is C

Explanation

The nurse is developing a teaching plan for a client with acute gastritis caused by drinking contaminated water. The nurse should emphasize the need to report the onset of which problem?

Correct Answer is D

Explanation

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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.