The nurse in the emergency department is caring for a client who has fallen 20 feet from a roof. While performing the primary assessment, what is the most important nursing intervention?

Remove clothing

Maintain cervical spine precaution

Perform a mental status exam

Assess for facial lacerations

Answer and Explanation

The Correct Answer is B

A. Remove clothing: While removing clothing may be necessary for a thorough assessment and treatment, maintaining cervical spine precaution takes precedence to prevent potential spinal cord injury in clients with a history of trauma, such as a fall from a significant height.

B. Maintain cervical spine precaution: Maintaining cervical spine precaution by stabilizing the cervical spine and immobilizing the neck is crucial to prevent further injury to the spinal cord in clients with a history of trauma until spinal injury is ruled out or managed.

C. Perform a mental status exam: While assessing the client's mental status is important for evaluating neurological function, it is not the first priority in a client with potential spinal cord injury following a fall.

D. Assess for facial lacerations: Assessing for facial lacerations is important for identifying and managing potential facial injuries, but it is not the first priority in the primary assessment of a client with a history of trauma and potential spinal cord injury.

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Correct Answer is C

Explanation

A. Placing the client with the head reclined back can increase the risk of aspiration and is not recommended.
B. Placing food in the affected side of the mouth could lead to choking, as the client may have reduced sensation or control on that side.
C. Encouraging the client to take small bites can help prevent choking and make swallowing easier.
D. While exercise might promote appetite, it is not directly related to feeding safety and should be discussed separately from swallowing instructions.

A. Turn the client's head to the side. B. Loosen the clothing around the client's waist. C. Document the time the seizure began. D. Check the client's motor strength.

Correct Answer is A

Explanation

A. Turn the client's head to the side: This action helps prevent aspiration by allowing any oral secretions or vomitus to drain out of the mouth, reducing the risk of airway obstruction and aspiration pneumonia.

B. Loosen the clothing around the client's waist: While it's important to ensure the client's safety during a seizure, addressing airway protection takes precedence over loosening clothing. Loosening clothing can be done after ensuring airway patency.

C. Document the time the seizure began: Documenting the time of onset is important for accurately assessing the duration of the seizure, but it is not the first action to take during an active seizure.

D. Check the client's motor strength: Assessing motor strength is important for evaluating the
client's condition after the seizure has ended, but it is not the first action to take during an active seizure. Ensuring airway protection and preventing injury are the priorities during the seizure.

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The nurse in the emergency department is caring for a client who has fallen 20 feet from a roof. While performing the primary assessment, what is the most important nursing intervention?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

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A nurse is in a client's room when the client begins having a tonic-clonic seizure. Which of the following actions should the nurse take first?

Correct Answer is A

Explanation

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