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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Nuchal rigidity is a sign of meningitis but not specifically indicative of increased ICP.
B. Restlessness can be a sign of increased ICP due to reduced cerebral perfusion.
C. Photophobia is a common symptom of meningitis but does not directly indicate increased ICP.
D. Positive Kernig's sign is another indicator of meningitis but, like nuchal rigidity, it is not specific to increased ICP.
Correct Answer is B
Explanation
A. Assess for the presence of chest pain: While chest pain should always be assessed in a comprehensive health history and physical examination, it is not specifically related to multiple sclerosis unless there are concurrent cardiac issues.
B. Inquire about urinary tract problems: Urinary symptoms such as urinary urgency, frequency, hesitancy, or incontinence are common in multiple sclerosis due to neurogenic bladder dysfunction. Therefore, it is essential to inquire about these symptoms to assess the extent of neurological involvement and provide appropriate management.
C. Inspect the skin for rashes or discoloration: While skin manifestations can occur in multiple sclerosis, they are less common and not typically primary concerns during initial assessment. However, if the patient reports skin changes, they should be evaluated accordingly.
D. Ask the patient about any increase in libido: Changes in libido are not typically associated with multiple sclerosis unless they are related to psychological or emotional factors. While sexual dysfunction can occur in MS, it is not the primary focus during the initial assessment unless the patient presents with related concerns.
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