Prior to completing the physical examination of a patient post motor vehicle crash, the ER nurse determines that the client is awake, alert, and oriented. This information would be important for which part of the general survey?

Facial expression.

Level of consciousness.

Posture, gait, motor activity, and speech.

Apparent state of health.

Answer and Explanation

The Correct Answer is B

Choice A reason:
Facial expression is an important aspect of the general survey as it can provide clues about a patient's emotional state and possible pain. However, it is not directly related to the patient's level of consciousness. After a motor vehicle crash, assessing facial expression is crucial to identify any signs of distress, trauma, or neurological impairment.
Choice B reason:
Level of consciousness is a critical component of the general survey, especially in the context of trauma or potential neurological injury. It refers to the patient's awareness and responsiveness to the environment. Assessing the level of consciousness involves determining if the patient is awake, alert, and oriented to time, place, and person, which is essential for establishing a baseline cognitive function and detecting any changes that may indicate deterioration or improvement in their condition.
Choice C reason:
Posture, gait, motor activity, and speech are assessed to evaluate the musculoskeletal and neurological systems. While these are important in the context of a motor vehicle crash, they are not specifically related to the level of consciousness. These assessments help identify any deficits that may result from injuries sustained during the crash, such as fractures, dislocations, or neurological damage affecting movement and coordination.
Choice D reason:
The apparent state of health is a broad assessment that includes the patient's overall appearance and any signs that may indicate acute or chronic illness. In the emergency setting, this may involve observing for signs of trauma, shock, or other life-threatening conditions. While it is an essential part of the general survey, it is not specifically focused on the level of consciousness but rather on the patient's general well-being and any obvious health concerns.

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Correct Answer is B

Explanation

Choice A Reason:
Rhinitis medicamentosa, also known as rebound congestion, is a condition of nasal congestion without other cold or allergy symptoms, typically caused by the overuse of nasal decongestant sprays. It does not usually present with chronic headaches or tenderness over the sinuses, which are more indicative of sinusitis.

Choice B Reason:
Acute bacterial sinusitis is likely the correct diagnosis in this scenario. It often follows a viral upper respiratory infection and presents with symptoms such as thick, discolored nasal mucus, decreased sense of smell, and facial pain or tenderness over the affected sinuses. The chronic headache and noted tenderness upon palpation over the sinuses in the client are consistent with this condition.

Choice C Reason:
Epistaxis, or nosebleed, is bleeding from the nose that can be caused by various factors, including trauma, medication, or environmental conditions. While it can be a symptom of other nasal conditions, it is not typically associated with chronic headaches or sinus tenderness following an upper respiratory infection.

Choice D Reason:
Allergic rhinitis is an allergic reaction to allergens such as pollen, dust, or pet dander, causing symptoms like sneezing, runny nose, itchy eyes, and sometimes headaches. However, the chronic headache and sinus tenderness described by the client after an infection are more suggestive of sinusitis rather than allergic rhinitis.

A. Falls occur more frequently in the younger population. B. Females have twice the risk that males do. C. Concussions in sports and motor vehicle accidents cause the largest number of TBIs in teens. D. Most firearm incidents are accidental.

Correct Answer is C

Explanation

Choice A Reason:
While falls are a common cause of injury in children, they are not the leading cause of TBI in adolescents. Falls tend to be more frequent in the younger population, particularly in children under the age of 4. In adolescents, sports-related injuries and motor vehicle accidents are more prevalent causes of TBI.

Choice B Reason:
The statement that females have twice the risk of TBI compared to males is incorrect. National data reveal that males are at increased risk of TBI compared to females, especially in the adolescent age group. This is likely due to higher engagement in risk-taking behaviors and contact sports.

Choice C Reason:
Concussions in sports and motor vehicle accidents are indeed the leading causes of TBI in adolescents. Engaging in contact sports such as football, hockey, and soccer can lead to concussions, which are a form of mild TBI. Motor vehicle accidents are also a significant risk factor due to high-impact collisions that can cause head injuries.

Choice D Reason:
Firearm incidents are a serious concern for TBI; however, they are not the most common cause of TBI in adolescents. While firearm-related injuries can be severe and are a leading cause of TBI-related deaths, concussions from sports and motor vehicle accidents account for a larger number of non-fatal TBIs in this age group.

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Prior to completing the physical examination of a patient post motor vehicle crash, the ER nurse determines that the client is awake, alert, and oriented. This information would be important for which part of the general survey?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client reports experiencing chronic headaches after a recent upper respiratory tract infection. On physical examination, the nurse notes tenderness when palpating over the sinuses. Which condition is likely?

Correct Answer is B

Explanation

Which risk factor for traumatic brain injury (TBI) should a nurse include in a discussion about prevention for a group of adolescents?

Correct Answer is C

Explanation

The nurse is planning to instruct a group of adolescents on ways to prevent traumatic brain injuries. What should be included in these instructions?

A nurse is performing a respiratory system physical examination. To assess the resonance of voice sounds heard during auscultation of the lungs, the nurse instructs the patient to say "ee," and if the sound is heard as "ay," this is known as:

During the physical examination of the mouth, the nurse identifies vesicular eruptions along the client's lips and surrounding skin. Which problem should the nurse document?

While conducting the health assessment, the nurse instructs the client about secondary prevention activities. What information did the nurse most likely provide to this client?

When conducting a physical examination of a client with generalized muscle weakness, which of the following is the PRIORITY for the nurse?

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A client has been receiving intravenous antibiotics (ototoxic) for several weeks. Which prevention strategy would be best for the nurse to recommend for this client?