A nurse in an emergency department is assisting with the care of a client who is unconscious and has trauma to multiple systems following a motor vehicle crash. Which of the following actions should the nurse take first?
Airway protection
Stabilizing cardiac arrhythmias
Preventing musculoskeletal disability
Decreasing intracranial pressure
The Correct Answer is A
Choice A reason: This action is correct because airway protection is the first priority for a client who is unconscious and has trauma to multiple systems. The nurse should assess the client's airway patency, breathing, and oxygenation, and intervene as needed to secure and maintain the airway. The nurse should also monitor the client for signs of aspiration, bleeding, or obstruction, and suction the airway as needed.
Choice B reason: This action is incorrect because stabilizing cardiac arrhythmias is not the first priority for a client who is unconscious and has trauma to multiple systems. The nurse should assess the client's circulation, blood pressure, and pulse, and intervene as needed to treat any arrhythmias, shock, or hemorrhage. However, this is not a priority over the client's airway, which is essential for survival.
Choice C reason: This action is incorrect because preventing musculoskeletal disability is not the first priority for a client who is unconscious and has trauma to multiple systems. The nurse should assess the client's mobility, sensation, and alignment, and intervene as needed to prevent or treat any fractures, dislocations, or nerve injuries. However, this is not a priority over the client's airway, which is essential for survival.
Choice D reason: This action is incorrect because decreasing intracranial pressure is not the first priority for a client who is unconscious and has trauma to multiple systems. The nurse should assess the client's level of consciousness, pupillary response, and neurological status, and intervene as needed to prevent or treat any increased intracranial pressure, cerebral edema, or brain injury. However, this is not a priority over the client's airway, which is essential for survival.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: The prodromal stage is the period between the exposure to the infectious agent and the onset of specific symptoms. During this stage, the person may experience mild and nonspecific signs of infection, such as fatigue or lowgrade fever. The client in the question has already developed specific symptoms of infection, such as sneezing, productive cough, and fever, which indicate that they have passed the prodromal stage.
Choice B reason: The period of convalescence is the stage of recovery after the infection. During this stage, the person's symptoms gradually subside, and their immune system eliminates the infectious agent from the body. The client in the question is still experiencing symptoms of infection, which suggest that they have not reached the period of convalescence yet.
Choice C reason: The acute illness stage is the peak of the infection, when the person exhibits the most severe and specific symptoms of the disease. During this stage, the person's immune system fights against the infectious agent, and the outcome of the infection is determined. The client in the question is likely in the acute illness stage, as they have been experiencing symptoms of infection for 4 days, and their condition has worsened over time.
Choice D reason: The incubation stage is the time between the entry of the infectious agent into the body and the appearance of the first symptoms of infection. During this stage, the person does not feel ill, but the infectious agent is multiplying in the body. The client in the question has already developed symptoms of infection, which indicate that they have left the incubation stage.
Correct Answer is D
Explanation
Choice A reason: SOAP documentation is not the correct method for documenting only unexpected findings. SOAP documentation requires the nurse to document both normal and abnormal findings, as well as the plan of care for the client.
Choice B reason: Problem oriented medical record (POMR) is not the correct method for documenting only unexpected findings. POMR is a method that organizes the documentation around the client's problems, rather than the source of data. It consists of four components: database, problem list, plan, and progress notes.
Choice C reason: Focus charting (DAR) is not the correct method for documenting only unexpected findings. Focus charting is a method that uses the nursing process and the client's perspective to document the client's care. It consists of three components: data, action, and response.
Choice D reason: Charting by exception (CBE) is the correct method for documenting only unexpected findings. CBE is a method that assumes that all standards of care are met unless otherwise documented. It allows the nurse to document only significant or abnormal findings, such as changes in the client's condition, interventions, or outcomes.
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