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 B

Explanation

A. Auscultate the bowel sounds: While gastrointestinal side effects such as nausea or
constipation can occur with phenytoin, auscultating bowel sounds is not a specific assessment related to its adverse effects.

B. Inspect the oral mucosa: Phenytoin is associated with gingival hyperplasia, a condition characterized by overgrowth of gum tissue. Therefore, inspecting the oral mucosa for signs of gum enlargement or other oral changes is important for evaluating adverse effects of phenytoin.

C. Check pupil reaction to light: Phenytoin does not typically affect pupil reaction to light. This assessment is more relevant for medications that act on the central nervous system or conditions affecting cranial nerve function.

D. Listen to the lung sounds: Phenytoin is not typically associated with respiratory side effects. Assessing lung sounds may be relevant in certain clinical situations, but it is not a specific assessment related to phenytoin adverse effects.

A. Apply an eye patch to the right eye. B. Teach the patient that the left visual deficit will resolve. C. Approach the patient from the right side. D. Place needed objects on the patient's left side.

Correct Answer is D

Explanation

A. Apply an eye patch to the right eye: Applying an eye patch to the right eye would further limit the patient's visual field, exacerbating the homonymous hemianopsia. This intervention is not appropriate for managing hemianopsia.

B. Teach the patient that the left visual deficit will resolve: Homonymous hemianopsia typically results from damage to the visual pathway in the brain and may not resolve completely. While visual rehabilitation techniques may help improve compensatory strategies, it is important to acknowledge and address the permanent nature of the deficit.

C. Approach the patient from the right side: Approaching the patient from the right side may startle them and increase the risk of falls or accidents due to the inability to perceive objects on their left side. The nurse should approach the patient from the unaffected side (the left side) to minimize the risk of injury.

D. Place needed objects on the patient's left side: Placing needed objects on the patient's left side helps compensate for the visual deficit by ensuring that essential items are within the patient's field of vision. This intervention promotes independence and safety for the patient with homonymous hemianopsia.

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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

A patient has been taking phenytoin (Dilantin) for 2 years. Which action should the nurse take when evaluating possible adverse effects of the medication?

Correct Answer is B

Explanation

Which intervention should the nurse include in the plan of care for a patient with new right- sided homonymous hemianopsia after a stroke?

Correct Answer is D

Explanation

A patient who has been treated for status epilepticus in the emergency department will be transferred to the medical nursing unit. Which equipment should the nurse have available in the patient's assigned room? (Select all that apply.)

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