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, A, D, C

B. The first priority in a primary survey is to open and maintain the airway; in a trauma client, this is done with a jaw-thrust maneuver to protect the cervical spine. E. After the airway is established, the nurse should assess breathing and determine the effectiveness of ventilatory efforts. A. Once airway and breathing are stabilized, circulation is addressed by establishing IV access for fluid or blood administration. D. Disability is assessed next using tools such as the Glasgow Coma Scale to evaluate neurologic status. C. Exposure is the final step; the nurse removes clothing to perform a thorough assessment while preventing hypothermia.

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Correct Answer is C

Explanation

A. The patient's blood pressure (BP) is 144/90 mm Hg: While elevated blood pressure may contribute to the risk of intracerebral hemorrhage, the patient's current BP is not excessively high and may not be the most critical factor in this situation compared to other factors such as anticoagulant use.

B. The patient takes a diuretic because of a history of hypertension: While the patient's history of hypertension and diuretic use are relevant to their overall health status, they may not be the most immediate concern in the context of intracerebral hemorrhage.

C. The patient has atrial fibrillation and takes warfarin (Coumadin): This information is crucial as it indicates that the patient is anticoagulated, which can significantly impact the severity and management of intracerebral hemorrhage. Anticoagulant use increases the risk of bleeding and can worsen outcomes in cases of intracranial hemorrhage.

D. The patient's speech is difficult to understand: While difficulty with speech may indicate neurological impairment, it is not as immediately concerning as the patient's anticoagulant use, which increases the risk of bleeding complications and may require specific interventions such as reversal agents.

A. Oriented to person, place, and year B. Severe headache C. Bradycardia D. Blurred vision

Correct Answer is B

Explanation

A. Oriented to person, place, and year: Meningitis often causes alterations in mental status, including confusion and disorientation. Therefore, the client may not be fully oriented to person, place, and time.

B. Severe headache: Headache is a hallmark symptom of meningitis and is often described as severe and persistent. It may be accompanied by other symptoms such as photophobia (sensitivity to light) and phonophobia (sensitivity to sound).

C. Bradycardia: Bradycardia is not typically associated with meningitis. In fact, tachycardia (elevated heart rate) may be present due to fever and systemic inflammation.

D. Blurred vision: While meningitis can lead to increased intracranial pressure, which may manifest as papilledema (swelling of the optic disc), blurred vision is not a common presenting symptom of meningitis. Visual changes are more commonly associated with conditions affecting the optic nerve or retina.

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Naxlex Comprehensive Predictor Exams

A patient in the emergency department with sudden-onset right-sided weakness is diagnosed with an intracerebral hemorrhage. Which information about the patient is most important to communicate to the health care provider?

Correct Answer is C

Explanation

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

Correct Answer is B

Explanation

A nurse is caring for a client who has an intracranial aneurysm and requires aneurysm precautions. Which of the following interventions should the nurse take?

A nurse is caring for a client who has quadriplegia from a spinal cord injury and reports having a severe headache. The nurse obtains a blood pressure reading of 210/108 mm Hg and suspects the client is experiencing autonomic dysreflexia. Which of the following actions should the nurse take first?

A nurse is caring for a client who has had a spinal cord injury at the level of the T2-T3 vertebrae. When planning care, the nurse should anticipate which of the following types of disability?

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 caring for a 24-year-old client who reports a recent fall, hitting their head and right shoulder. Exhibits Complete the following sentence by using the list of options. The nurse should first address the client's dropdown followed by the client's dropdown

Which problem should the nurse expect for a patient who has a positive Romberg test result?

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)?