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 A

Explanation

A. BP 190/84, HR 50, and an irregular respiratory pattern is characteristic of Cushing's triad, a classic sign of increased intracranial pressure (ICP). Cushing's triad includes hypertension with a widened pulse pressure, bradycardia, and irregular or abnormal respirations. The elevated blood pressure occurs as a compensatory mechanism to maintain cerebral perfusion, while bradycardia and irregular respirations result from brainstem compression.

B. BP 190/84, HR 150, and an irregular respiratory pattern is incorrect because tachycardia (HR 150) is not part of Cushing's triad. Increased ICP typically causes bradycardia due to brainstem involvement.

C. BP 80/50, HR 50, and Kussmaul respirations: Kussmaul respirations are deep, rapid respirations commonly seen in metabolic acidosis, not typically associated with increased intracranial pressure.
D. BP 80/50, HR 150, and Cheyne-Stokes respirations: Cheyne-Stokes respirations are characterized by alternating periods of deep breathing followed by apnea and are often seen in conditions affecting the brainstem, but they are not specific to increased intracranial pressure.

A. Call the health care provider if stools are tarry. B. Clopidogrel will reduce cerebral artery plaque formation. C. Clopidogrel will dissolve clots in the cerebral arteries. D. Monitor and record the blood pressure daily.

Correct Answer is B

Explanation

A. Call the health care provider if stools are tarry: This instruction is more relevant to medications such as aspirin or NSAIDs, which can increase the risk of gastrointestinal bleeding.
Clopidogrel, while also an antiplatelet medication, is less likely to cause gastrointestinal bleeding compared to aspirin.

B. Clopidogrel will reduce cerebral artery plaque formation: Clopidogrel is an antiplatelet
medication that inhibits platelet aggregation, thereby reducing the formation of blood clots and potentially slowing the progression of atherosclerosis by preventing further plaque formation.

C. Clopidogrel will dissolve clots in the cerebral arteries: While clopidogrel can help prevent the formation of new clots, it does not actively dissolve existing clots in the cerebral arteries. Its primary mechanism of action is to inhibit platelet aggregation and prevent clot formation.

D. Monitor and record the blood pressure daily: While monitoring blood pressure is important for managing cerebral atherosclerosis and reducing the risk of stroke, it is not directly related to the action of clopidogrel. Blood pressure management may involve lifestyle modifications and other medications but is not specific to clopidogrel administration.

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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

The nurse anticipates that the client presenting with increased intracranial pressure would most likely exhibit which set of vital signs?

Correct Answer is A

Explanation

What will the nurse tell the patient who has cerebral atherosclerosis about taking clopidogrel?

Correct Answer is B

Explanation

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