22. A nurse is conducting a primary survey of a client who has sustained life-threatening injuries due to a motor-vehicle crash. Identify the sequence of actions the nurse should take. (Move the actions into the box on the right, placing them in the selected order of performance. Use all the steps.)

Establish IV access.

Open the airway using a jaw-thrust maneuver.

Remove clothing for a thorough assessment.

Perform a Glasgow Coma Scale assessment..

Determine effectiveness of ventilator efforts.

Answer and Explanation

The Correct Answer is B, E, D, A, C

B. The first action in a primary survey is to open the airway to ensure it is not obstructed, especially if the client is unconscious or has altered mental status.

E. Once the airway is secured, determining the effectiveness of ventilatory efforts is essential to ensure adequate oxygenation.

D. After airway and breathing are addressed, performing a Glasgow Coma Scale assessment helps determine the level of consciousness and neurological status.

A. Establishing IV access is crucial for fluid resuscitation and medication administration but is not the first step in a primary survey.

C. Finally, removing clothing is necessary for a thorough assessment, but it comes after the critical steps of airway, breathing, and circulation have been addressed.

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Correct Answer is A

Explanation

A. Place suction equipment at the client's bedside: Impairment of cranial nerves IX and X can lead to difficulty swallowing and impaired gag reflex, increasing the risk of aspiration and airway obstruction. Therefore, having suction equipment readily available is essential to maintain a patent airway and manage secretions effectively.

B. Provide range-of-motion exercises to the client's neck and shoulders: While range-of-motion exercises may be beneficial for preventing muscle stiffness and contractures, they are not directly related to the client's risk of airway compromise or aspiration.

C. Apply an eye patch to the client's right eye: Acoustic neuroma typically affects cranial nerves VII and VIII, leading to symptoms such as hearing loss and facial weakness. Applying an eye patch to the client's right eye is not necessary for cranial nerve IX and X impairment unless there are specific ocular symptoms.

D. Avoid the use of warm water to wash the client's face: Warm water may be used to wash the client's face safely and is not contraindicated specifically for a client with impairment of cranial nerves IX and X. However, precautions should be taken to ensure that water does not enter the airway if the client has difficulty swallowing or impaired gag reflex.

A. Hyperthermia B. Weakened gag reflex C. Absence of bowel sounds D. Hypotension E. Polyuria

Correct Answer is ["B","D"]

Explanation

A. Slurred speech: This can be a sign of increased ICP but is not typically considered a late sign. It is more often associated with early or moderate increases in ICP when the brain is starting to experience pressure but is not yet at a critical stage.
B. Bradycardia: This is a late sign of increased ICP and is part of Cushing's triad, which includes bradycardia, irregular respirations, and a widened pulse pressure. Bradycardia occurs as a compensatory mechanism to decrease the cerebral blood flow in response to increased ICP.
C. Hypotension: While changes in blood pressure can be associated with ICP, hypotension is not typically a late sign of increased ICP. In fact, hypertension with a widened pulse pressure would be more indicative of increased ICP as part of Cushing's triad.
D. Nonreactive dilated pupils: This is a late sign of increased ICP and indicates brain stem herniation or compression, which is a medical emergency. The pupils become fixed and dilated as the oculomotor nerve is compressed due to increased pressure.
E. Confusion: Confusion can be an early sign of increased ICP as it indicates changes in mental status. However, it is not specifically a late sign of increased ICP, as it can occur at various stages of pressure changes within the brain.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has right-sided acoustic neuroma resulting in impairment of cranial nerves IX and X. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

A nurse in the emergency department is monitoring a client who has a cervical spinal cord injury from a fall. The nurse should monitor the client for which of the following complications? (Select all that apply.)

Correct Answer is ["B","D"]

Explanation

A nurse is assessing a client who has meningitis. Which of the following findings should the nurse expect?

A nurse is receiving a transfer report for a client who has a head injury. The client has a Glasgow Coma Scale (GCS) score of 3 for eye opening, 5 for best verbal response, and 5 for best motor response. Which of the following is an appropriate conclusion based on this data?

A nurse is performing a neurological assessment for a client who has head trauma. Which of the following assessments will give the nurse information about the function of cranial nerve III?

A nurse is presenting discharge instructions to a client who has multiple sclerosis (MS). The client reports symptoms of diplopia, dysmetria, and sensory change. Which of the following nursing statements are appropriate?

What action should the nurse include in completing a health history and physical assessment for a 36-yr-old female patient with possible multiple sclerosis (MS)?

A nurse is caring for a client who has a traumatic brain injury. Which of the following findings should the nurse identify as an indication of increased intracranial pressure (ICP)?

A nurse is instructing a client's family members about feeding safety for a client who has dysphagia following a stroke. Which of the following instructions should the nurse include?

A nurse is creating a plan of care for a client who has a history of tonic-clonic seizure disorder. Which of the following interventions should the nurse include? (Select all that apply.)