When performing an initial assessment on a patient, which piece of information is of highest priority?

date of previous diagnostic tests

where the patient is living

treatment for previous illnesses

any allergies to medications

Answer and Explanation

The Correct Answer is D

A.   The date of previous diagnostic tests may be important, but it is secondary to immediate safety concerns like allergies.
B.   Information about the patient's living situation can be useful for discharge planning but is not the most urgent piece of information.
C.   Previous treatment for illnesses is important but does not supersede immediate health threats like allergies.
D.   Knowing any allergies to medications is critical to avoid potentially harmful reactions. This is a priority when beginning care, as it informs medication administration and treatment options.

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Correct Answer is A

Explanation

A. This is because the patient's blood pressure of 98/66 mm Hg, while on the lower side, may be normal for them. It's important to compare it to their baseline to determine if there has been a significant change.
B. The blood pressure is within a normal range for an adult, so immediate notification of hypotension is not required.
C. This can be done after determining if there is a significant change from the baseline.
D. The pulse is not bradycardic (it is within a normal range), so there is no immediate need to notify the doctor regarding bradycardia.

A. auscultate lung and abdominal sounds. B. check for verbal and motor response. C. monitor daily weight. D. monitor intake and output.

Correct Answer is B

Explanation

A. While auscultating lung and abdominal sounds is important, it is not as urgent as checking neurological function in a head trauma patient.
B. Assessing verbal and motor responses is critical to evaluate the level of consciousness and neurological function in a patient with head trauma.
C. Monitoring daily weight is not an immediate concern for a patient with possible head trauma.
D. Monitoring intake and output is important but not the priority compared to assessing the neurological status in head trauma patients.

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When performing an initial assessment on a patient, which piece of information is of highest priority?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A 45-year-old patient who is alert and oriented has a blood pressure of 98/66 mm Hg, radial pulse of 76 beats/min (irregular), and respirations of 18 breaths/min (regular). The best nursing intervention is to:

Correct Answer is A

Explanation

A patient was admitted with possible head trauma after a motor vehicle accident. The nursing implementation with the highest priority is to:

Correct Answer is B

Explanation

If a silence is heard between sounds when auscultating blood pressure, it is termed a(n)

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A nurse is instructing a nursing student on performing pupillary checks on a patient with a possible head injury. Which statement indicates that the nursing student understands the concept?

A nurse is checking a client's bowel sounds. At which of the following times should the nurse auscultate the client's abdomen?