The client is a 26-year-old female who fell from an apartment balcony. She was transported to the hospital via ambulance.

The client enters the emergency room on a stretcher and is met in the trauma bay by the nurse.

What two actions should the nurse take first during the primary survey?

Choice A rationale
Sudden onset of confusion in an older adult could be a sign of a urinary tract infection (UTI). UTIs can cause delirium and behavioral changes in older adults. Therefore, asking if the client is experiencing any pain with urination could help identify a potential UTI.
Choice B rationale
While high protein foods are generally beneficial for health, there is no direct link between increased intake of high protein foods and sudden onset of confusion. Therefore, this option is not the most appropriate action in this situation.
Choice C rationale
Reviewing the client’s current food and medication allergies is always important in healthcare settings. However, it may not directly address the sudden onset of confusion unless the client has had a recent change in diet or medication that could have triggered an allergic reaction leading to confusion.
Choice D rationale
A recent fall could potentially cause a sudden change in mental status due to a head injury or other trauma. Therefore, determining if the client has recently experienced a fall is an appropriate action.
Choice E rationale
Fever can cause confusion, especially in older adults. Therefore, providing instruction on taking the client’s temperature can help the caregiver monitor for signs of infection that could be contributing to the client’s confusion.

Choice A rationale
Monitoring leukocytes, neutrophils, and thyroxine is not the most crucial for a patient with end-stage renal disease (ESRD). While these lab values can provide information about the patient’s immune function and thyroid function, they do not directly relate to the patient’s renal function.
Choice B rationale
Monitoring serum potassium, calcium, and phosphorus levels is crucial for a patient with ESRD. These electrolytes are typically excreted by the kidneys, and their levels can become imbalanced in patients with ESRD. Imbalances can lead to serious complications, such as cardiac arrhythmias and bone disease.
Choice C rationale
Monitoring erythrocytes, hemoglobin, and hematocrit is important for a patient with ESRD, as these patients often develop anemia due to decreased erythropoietin production by the kidneys. However, these are not the only lab values that should be monitored in these patients.
Choice D rationale

Monitoring blood pressure, heart rate, and temperature is important for all patients, but these are not specific to patients with ESRD. Patients with ESRD are at risk for electrolyte imbalances, which can affect cardiac function, making monitoring of serum potassium, calcium, and phosphorus levels more crucial.