When applying the principle of ABC (airway, breathing, circulation) prioritization, which complication is priority for the nurse to address?

Wound infection

Bacteremia

Aspiration pneumonia

Urinary tract infection

Answer and Explanation

The Correct Answer is C

A. Wound infection: While important to address, a wound infection does not directly impact airway, breathing, or circulation unless it leads to severe complications.

B. Bacteremia: This condition is serious and can lead to sepsis, which affects circulation, but immediate airway and breathing issues take precedence.

C. Aspiration pneumonia: This directly affects breathing by causing respiratory complications, making it a priority when considering airway and breathing issues.

D. Urinary tract infection: Although it requires treatment, it does not immediately impact airway, breathing, or circulation like aspiration pneumonia can.

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Correct Answer is C

Explanation

A. Apparent state of health: This generally reflects overall health rather than specific mental or cognitive status.

B. Facial expression: Facial expression provides insight into mood and emotional state but does not specifically assess consciousness or orientation.

C. Level of consciousness: Being awake, alert, and oriented is directly related to the level of consciousness, which is a key aspect of assessing cognitive and mental function.

D. Posture, gait, motor activity, and speech: These aspects are relevant for physical activity and motor skills, not specifically for consciousness or cognitive orientation.

A. Mental status examination B. Mouth and throat C. Head and face D. Ears E. Hematocrit 47% (37% to 47%)

Correct Answer is D

Explanation

A. Mental status examination: This part of the assessment evaluates cognitive functions, not sensory functions related to cranial nerve VIII.

B. Mouth and throat: This area assesses cranial nerves related to swallowing and speech but not the sensory function of cranial nerve VIII.

C. Head and face: This includes assessing cranial nerves related to facial sensation and movement but not the auditory function of cranial nerve VIII.

D. Ears: Cranial nerve VIII, the vestibulocochlear nerve, is responsible for hearing and balance, so assessing sensory function related to this nerve occurs during the examination of the ears.

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When applying the principle of ABC (airway, breathing, circulation) prioritization, which complication is priority for the nurse to address?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Before completing the physical examination, the nurse determines that the client is awake, alert, and oriented. This information would be important for which part of the general survey?

Correct Answer is C

Explanation

When performing a head-to-toe assessment, during which part would the nurse assess the sensory function of cranial nerve VIII?

Correct Answer is D

Explanation

When planning care for a client with an inner ear infection, the nurse will need to include interventions for which of the following potential problems?

The nurse is performing the technique shown. What is the nurse assessing?

When the nurse collects objective data, which finding requires immediate follow-up?

The nurse who has been assigned to a client on the second shift is assessing a client to evaluate the outcomes identified in the care plan. This nurse is conducting which type of assessment?

During a health history, which of the following can the nurse ask to determine an older adult client's abilities to conduct instrumental activities of daily living? (Select all that apply.)

The nurse is conducting a health history with a female client who reports upper back and jaw pain. In order to assess the client's risk for a cardiac event, which question should the nurse ask first?

The nurse instructs a female client on breast self-examination. Why does the nurse recommend the pattern shown for the client to use?

While inspecting the external eye of a client, the nurse notes that the client's right eyelid droops. Which term would the nurse use to document this finding?