The client is brought to the ER after falling off a roof and landing on his back. A T4 spinal fracture is diagnosed. The client's blood pressure is 74/40 mmHg, pulse is 55/min, and skin is pink and dry. What of the following nursing actions is a priority?

Determine if blood is present in urine

Perform a neurological assessment

Administer IV normal saline

Perform a 12-lead electrocardiogram

Answer and Explanation

The Correct Answer is C

Choice A rationale: Although important to assess for potential kidney injury, addressing hypotension due to potential spinal shock takes priority.

Choice B rationale: Important for determining any neurological deficits, but addressing hypotension is the initial priority.

Choice C rationale: Hypotension indicates potential spinal shock or hemorrhagic shock, and fluid resuscitation is the immediate priority to stabilize the client's blood pressure.

Choice D rationale: While important for assessing cardiac status, addressing hypotension takes precedence to stabilize the client's condition.

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Correct Answer is D

Explanation

Choice A rationale: A breast lump that increases in size before the menstrual period might be related to hormonal changes and is not necessarily indicative of a concerning issue.

Choice B rationale: Bilateral breast nodules that are tender with palpation might be related to benign conditions or hormonal changes.

Choice C rationale: A small, mobile, rubbery breast lump could suggest a benign condition like a fibroadenoma, which might not be as concerning.

Choice D rationale: A breast nodule that is 1 cm in size, nontender, and fixed could potentially raise concerns about malignancy and requires further evaluation.

A. Smokes 1 pack of cigarettes per day B. Drinks one alcoholic beverage per day C. Large body stature D. History of bone fracture during childhood

Correct Answer is A

Explanation

Choice A rationale: Smoking is a risk factor for osteoporosis as it can interfere with calcium absorption and decrease bone density.

Choice B rationale: Moderate alcohol consumption isn't a significant risk factor for osteoporosis.

Choice C rationale: Generally, having a larger body stature is not considered a significant risk factor for osteoporosis.

Choice D rationale: While fractures during childhood can affect bone health, they might not necessarily predict osteoporosis risk in adulthood.

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The client is brought to the ER after falling off a roof and landing on his back. A T4 spinal fracture is diagnosed. The client's blood pressure is 74/40 mmHg, pulse is 55/min, and skin is pink and dry. What of the following nursing actions is a priority?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which assessment finding in a 36-yr-old patient is most indicative of a need for further evaluation?

Correct Answer is D

Explanation

A nurse in a clinic is assessing a client. Which of the following findings should the nurse identify as a risk factor for osteoporosis?

Correct Answer is A

Explanation

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