The nurse understands the primary assessment for a patient following a major trauma:
includes the head-to-toe anterior and posterior assessment
focuses on the ABCDE's to identify life threating problems
includes the use of a standard pain scale and past medical/surgical history
consists of analyzing the results of the diagnostic testing
The Correct Answer is B
A) Includes the head-to-toe anterior and posterior assessment:
While a head-to-toe physical assessment is important in trauma care, it is not the first priority. The primary assessment focuses on immediate life-threatening conditions, and the head-to-toe assessment would come after the initial stabilization of the patient's airway, breathing, circulation, and disability. A comprehensive physical examination is crucial but secondary to addressing urgent life threats.
B) Focuses on the ABCDE's to identify life-threatening problems:
The ABCDE's (Airway, Breathing, Circulation, Disability, Exposure) are the primary framework for assessing and stabilizing a trauma patient. This approach is used to identify and prioritize life-threatening problems. It ensures that the most critical issues, such as airway obstruction, respiratory failure, shock, and neurological deficits, are addressed first. This protocol is the gold standard in trauma care and is the most appropriate initial assessment in major trauma.
C) Includes the use of a standard pain scale and past medical/surgical history:
While it is important to assess pain and gather a medical history in the trauma patient, these are secondary considerations after addressing immediate threats to life. Pain management and obtaining a full history are crucial, but they are not as urgent as addressing airway, breathing, and circulation issues. These should be part of a more detailed secondary assessment once the patient is stable.
D) Consists of analyzing the results of the diagnostic testing:
Diagnostic testing, such as imaging studies and lab work, are important but are not the first priority. The primary assessment should focus on the ABCDE's. Diagnostic results are typically analyzed after the patient is stabilized, as they provide additional information but do not address immediate survival needs.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A) Be placed in isolation to prevent radiation exposure to others:
Radioactive iodine (I-131) is commonly used to treat thyroid cancer because it targets and destroys thyroid tissue, including any remaining cancerous cells. This treatment involves the administration of a radioactive substance that can be excreted through saliva, urine, and sweat. To minimize radiation exposure to others, patients are often placed in isolation, particularly in a hospital setting, for a period following administration.
B) Avoid consuming any food or fluids for 24 hours prior to the treatment:
While it’s essential for patients to follow specific instructions regarding food and fluid intake, such as avoiding certain foods or fluids that may interfere with absorption or increase the risk of side effects (like dairy products), the patient does not need to avoid all food and fluids for 24 hours after receiving radioactive iodine.
C) Avoid all physical activity for six weeks after the treatment:
While some precautions, such as avoiding close contact with others for a short period of time, may be necessary, avoiding physical activity for six weeks is not usually required. Patients may be advised to take it easy during the initial recovery phase, but they can typically resume normal activities once the initial isolation period is complete and their radiation exposure is below safety thresholds.
D) Discontinue all other medications for a week before treatment:
However, certain medications that affect thyroid function (such as thyroid hormones or antithyroid medications) may need to be adjusted or stopped before treatment to ensure the effectiveness of the radioactive iodine. The specifics would depend on the patient’s condition and the healthcare provider’s instructions.
Correct Answer is C
Explanation
A) Prevent the drainage by applying a tight pressure dressing:
Applying a tight pressure dressing is not the appropriate intervention in this case. The presence of fluid draining from the ear, particularly a yellow stain, could indicate cerebrospinal fluid (CSF) leakage, which is a potential sign of a skull fracture or traumatic brain injury (TBI) involving the base of the skull. Applying a tight pressure dressing could potentially increase pressure or cause further injury.
B) Administer antibiotics due to increased risk of infection:
While there is an increased risk of infection with a CSF leak, antibiotics should not be administered immediately unless there is clear evidence of an infection. The priority action is to identify whether the fluid is CSF, as antibiotics alone will not address the underlying issue of a CSF leak. The nurse should allow the fluid to drain, collect a sample, and notify the healthcare provider for further assessment, which may include imaging or testing for the presence of CSF.
C) Allow fluid to drain from the patient's ear onto gauze and notify the healthcare provider:
The yellow stain around the fluid dripping from the patient's ear suggests the possibility of CSF leakage, a sign of a skull base fracture. CSF leakage may occur after a traumatic brain injury and should be handled carefully. The nurse's priority action is to allow the fluid to drain onto gauze to prevent the buildup of pressure and to prevent further leakage into the ear canal. The nurse should also immediately notify the healthcare provider for further evaluation and management.
D) Hang intravenous (IV) fluids to replace fluids lost and prevent dehydration:
While IV fluids may be necessary in some cases for patients with trauma, the priority in this situation is to identify the source and nature of the drainage. If the fluid is CSF, it may be important to manage the leak appropriately rather than focusing solely on replacing fluids. The nurse should first confirm whether the fluid is CSF and notify the healthcare provider for further assessment and management. Replacing fluids may be necessary, but it is not the immediate priority.
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