A client arrives to the emergency department after losing consciousness during a soccer game. Which of the following actions should the nurse take first?
Prepare the client for an X-Ray.
Calculate a Glasgow Coma Score.
Dim the lights and turn off the TV.
Provide analgesics.
The Correct Answer is B
Choice A reason: This is incorrect because preparing the client for an X-ray is not the first action that the nurse should take. An X-ray can help diagnose possible injuries or fractures, but it is not an urgent test. The nurse should first assess the client's level of consciousness and neurological status using a standardized tool such as the Glasgow Coma Scale.
Choice B reason: This is the correct answer because calculating a Glasgow Coma Score is the first action that the nurse should take. The Glasgow Coma Scale is a tool that measures the level of consciousness based on the eye-opening, verbal response, and motor responses. It can help determine the severity of brain injury and guide further interventions.
Choice C reason: This is incorrect because dimming the lights and turning off the TV are not the first actions that the nurse should take. These are environmental modifications that can help reduce sensory stimulation and prevent agitation or seizures, but they are not as important as assessing the level of consciousness and neurological status.
Choice D reason: This is incorrect because providing analgesics is not the first action that the nurse should take. Analgesics can help relieve pain and discomfort, but they can also alter the level of consciousness and mask neurological signs. The nurse should first assess the level of consciousness and neurological status, and then administer analgesics as prescribed.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: This is incorrect because increasing her voice when speaking to the client may not prevent complications, but rather annoy or offend the client. The nurse should not assume that a client with a visual impairment has a hearing impairment as well unless it is confirmed by assessment or history. The nurse should speak in a normal tone and volume and identify herself by name and role.
Choice B reason: This is incorrect because lowering the bed rails before lowering the bed may increase the risk of complications, such as falls or injuries. The nurse should keep the bed rails up until the client is ready to get out of bed and lower them only when necessary. The nurse should also lock the wheels of the bed and adjust it to a comfortable height for the client.
Choice C reason: This is incorrect because using hand gestures to point to where the client will walk may not prevent complications, but rather confuse or frustrate the client. The nurse should not use visual cues or gestures that are meaningless to a client with a visual impairment. The nurse should use verbal directions and descriptions instead, such as "The restroom is on your left, about 10 steps away."
Choice D reason: This is correct because standing slightly in front and to one side of the client can prevent complications, such as collisions or falls. The nurse should guide the client by offering her arm or shoulder for support and walking slightly ahead of him or her. The nurse should also warn the client about any obstacles or changes in terrain, such as stairs, doors, or rugs.
Correct Answer is D
Explanation
Choice A Reason: A heart rate of 122/min is elevated, but not life-threatening. It could be due to pain, anxiety, dehydration, or infection.
Choice B Reason: A urinary output of 25 ml/hr is low, but not critical. It could indicate fluid loss, kidney damage, or inadequate fluid resuscitation.
Choice C Reason: A pain level of 6 on a scale of 0 to 10 is moderate, but not severe. It could be managed with analgesics and non-pharmacological interventions.
Choice D Reason: This is the correct answer because difficulty swallowing can indicate airway obstruction, inhalation injury, or edema of the throat. It can compromise breathing and require immediate intervention.
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