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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale: candidiasis - The described symptoms of inflammation, cottage
cheese-like discharge, and vaginal/vulvar inflammation are indicative of a yeast infection or candidiasis.
Choice B rationale: Chlamydia - Chlamydia often presents with different symptoms such as discharge, but it's not typically associated with a cottage cheese-like appearance.
Choice C rationale: bacterial vaginosis - Bacterial vaginosis typically presents with a different type of discharge, often described as "fishy" smelling, rather than a cottage cheese appearance.
Choice D rationale: trichomoniasis - Symptoms of trichomoniasis usually include frothy, malodorous discharge, not consistent with the described cottage cheese-like discharge.
Correct Answer is D
Explanation
Choice A rationale: While gastrointestinal issues like loose stools can occur in Parkinson's disease due to impaired bowel movements, they are not the highest risk related to dietary considerations. Choking might occur due to dysphagia, but it's not specifically the highest risk.
Choice B rationale: Drooling, due to weakened or uncoordinated swallowing muscles, is common in Parkinson's disease but might not pose the highest risk. A loss of appetite can occur but might not be the highest dietary risk for the client.
Choice C rationale: Constipation is a common gastrointestinal issue in Parkinson's disease, but though problematic, it's not the highest risk concerning dietary considerations. Drooling can also be present but might not be the primary dietary concern.
Choice D rationale: Parkinson's disease often leads to dysphagia (difficulty swallowing) and aspiration (inhalation of food or liquids into the lungs). These present significant risks related to dietary considerations, as they can lead to serious complications such as pneumonia due to aspiration.
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