A child has just arrived by ambulance at the emergency room following a motor vehicle accident and a nurse is assessing him.
Which three body systems should the nurse evaluate first?
Respiratory, cardiovascular, and skeletal.
Respiratory, cardiovascular, and neurologic.
Cardiovascular, gastrointestinal, and neurologic.
Neurologic, cardiovascular, and endocrine.
The Correct Answer is B
Choice A rationale
The immediate assessment of a trauma client follows a systematic approach known as the primary survey, prioritizing life-threatening injuries based on the ABCs (Airway, Breathing, Circulation). While the skeletal system is assessed in the secondary survey, initial focus must be on the respiratory and cardiovascular systems to ensure adequate oxygenation and perfusion, followed by a rapid neurologic assessment (Disability).
Choice B rationale
Following any motor vehicle accident, the nurse's priority in the emergency setting is the primary survey, which mandates immediate evaluation of the Respiratory (Airway and Breathing), Cardiovascular (Circulation), and Neurologic (Disability) systems. These three systems are fundamental to maintaining life, and compromise in any of them, such as inadequate ventilation or brain injury, requires immediate, life-saving intervention before proceeding to a more detailed, secondary assessment.
Choice C rationale
Gastrointestinal assessment is part of the secondary survey, focusing on potential abdominal injuries, and is not one of the immediate life-saving priorities. The neurologic system, crucial for determining brain function and spinal cord injury, must be assessed immediately after circulation, while the respiratory and cardiovascular systems must be addressed first to prevent irreversible damage.
Choice D rationale
The endocrine system, which regulates hormones and metabolism, is assessed later during the secondary survey or ongoing monitoring. It is not an immediate life-saving priority following acute trauma. The primary focus must remain on the ABCs (Airway, Breathing, Circulation) and Disability (Neurologic assessment) to identify and treat injuries that pose the most immediate threat to the child's survival.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Being easily distracted from playing is a common finding in many children and is a hallmark symptom of Attention-Deficit/Hyperactivity Disorder (ADHD), not a core diagnostic feature of Autism Spectrum Disorder (ASD). Children with ASD often exhibit hyperfocus or intense, restricted interests and may resist interruption of their preferred activities or routines, showing low rather than high distractibility within their focus.
Choice B rationale
Hypersensitivity to touch, along with other sensory input irregularities (hypo- or hypersensitivity to sound, light, taste, or smell), is a common finding in children with Autism Spectrum Disorder (ASD). This sensory processing difference contributes to difficulties with daily functioning, social interaction, and emotional regulation, making it a key supportive characteristic for the suspected diagnosis.
Choice C rationale
Children with typical development show distinct interest in others around them and often seek out social interaction and engagement, which is essential for forming relationships. A key diagnostic criterion for ASD is persistent deficits in social communication and social interaction, which typically manifests as a lack of interest in or difficulty engaging with peers and sharing emotions, supporting the opposite finding.
Choice D rationale
Engaging in conversations with an imaginary friend is considered a normal, healthy part of imaginative, symbolic play development in many preschool-aged children (typically between 3 and 7 years old). In contrast, children with ASD often demonstrate deficits in symbolic or imaginative play and are more likely to engage in repetitive play patterns or use objects in non-functional ways.
Correct Answer is A
Explanation
Step 1 is: Calculate the minimum safe dose for 24 hours. 5 mcg/kg/24 hr × 16.1 kg = 80.5 mcg/24 hr.
Step 2 is: Calculate the maximum safe dose for 24 hours. 6 mcg/kg/24 hr × 16.1 kg = 96.6 mcg/24 hr.
Step 3 is: Compare the ordered dose to the safe range. The ordered dose is 150 mcg. The safe dose range is 80.5 mcg to 96.6 mcg. The ordered dose (150 mcg) is higher than the maximum safe dose (96.6 mcg). The ordered dose is NOT safe, so the initial answer is B. However, the question choices are A. Yes, B. No, C. The dose is too low for the client's weight, D. The safe dose range is too narrow to determine. Since the ordered dose is too high, the most accurate choice indicating it is NOT safe is "No".
Choice A rationale
The statement "Yes" is incorrect because the ordered dose of 150 mcg is significantly above the calculated safe range maximum of 96.6 mcg/24 hr. Administering an overdose of levothyroxine can lead to hyperthyroidism symptoms like tachycardia, heat intolerance, and anxiety, which is not a safe practice.
Choice B rationale
The statement "No" is correct because the ordered dose of 150 mcg is not within the therapeutic and safe range of 80.5 mcg to 96.6 mcg for a 16.1 kg child. Dosing levothyroxine accurately is crucial as it has a narrow therapeutic index, and excess dosage carries risks of serious cardiac side effects.
Choice C rationale
The statement "The dose is too low for the client's weight" is incorrect. The maximum safe dose is 96.6 mcg, and the ordered dose is 150 mcg, which makes the ordered dose too high, not too low. Giving an excessively high dose can cause adverse effects due to drug toxicity or an induced hypermetabolic state in the body systems.
Choice D rationale
The statement "The safe dose range is too narrow to determine" is incorrect. The safe dose range is clearly defined by the provided parameters as 80.5 mcg to 96.6 mcg/24 hr. The calculation provides a precise and sufficient range to determine that the ordered dose of 150 mcg is clearly unsafe and should be questioned by the nurse.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.