A nurse in the emergency department is assessing a client who was brought in by a neighbor after falling down suddenly while walking. Which of the following assessments are the priority for the nurse to complete?(Select All that Apply.)

Muscle strength

Facial symmetry

Peripheral pulses

Vision changes

Aphasia

Answer and Explanation

Correct Answer : A,B,D

Choice A Reason:

Muscle strength is correct. Assessing muscle strength is essential to determine if there are any neurological deficits or weakness that could indicate a neurological condition or injury. Sudden falls can be indicative of various neurological issues, such as stroke or transient ischemic attack (TIA). Assessing muscle strength helps identify any motor impairments or weakness that could contribute to the fall.

Choice B Reason:

Facial symmetry is correct. Assessing facial symmetry is crucial to identify any signs of facial droop, which could indicate a neurological deficit such as a stroke or Bell's palsy. Facial asymmetry may suggest damage to the facial nerve or other neurological issues.

Choice C Reason:

Peripheral pulses is incorrect. While assessing peripheral pulses is important for evaluating circulation, it may not be the priority assessment in this scenario where the client has suddenly fallen and may be experiencing neurological symptoms. Neurological deficits, such as weakness or changes in facial symmetry, vision, or speech, are more indicative of acute neurological issues like stroke or transient ischemic attack (TIA), which require immediate attention and intervention. In emergency situations, prioritizing assessments related to potential life-threatening conditions such as neurological deficits takes precedence over assessing peripheral pulses.

Choice D Reason:

Vision changes is correct. Assessing for vision changes is important to identify any visual disturbances or deficits that could contribute to falls or indicate underlying neurological issues such as a stroke or transient ischemic attack (TIA). Visual disturbances may include blurriness, double vision, or loss of vision in one or both eyes.

Choice E Reason:

Aphasia is incorrect. Assessing for aphasia, which is the inability to understand or express speech, is essential to identify any language deficits that could indicate a neurological condition such as a stroke. Aphasia may present as difficulty speaking, understanding language, or both.

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Correct Answer is ["B","C","E"]

Explanation

Choice A Reason:

Photosensitivity is incorrect. Photosensitivity, or sensitivity to light, is not a common symptom of multiple sclerosis. While individuals with MS may experience visual disturbances, such as blurred vision or optic neuritis, sensitivity to light is not typically reported as a primary symptom.

Choice B Reason:

Memory issues is correct. Memory issues, including problems with short-term memory, concentration, and cognitive processing speed, are common neurological symptoms in individuals with multiple sclerosis. Cognitive impairment can affect various aspects of memory and cognitive function.

Choice C Reason:

Lhermitte's sign is correct. Lhermitte's sign is a classic neurological sign characterized by an electric shock-like sensation that radiates down the spine or into the limbs upon flexing the neck. It is a common symptom in multiple sclerosis, often associated with cervical spinal cord lesions.

Choice D Reason:

Seizures is incorrect. Seizures are not a typical symptom of multiple sclerosis. While individuals with MS may experience various neurological symptoms, seizures are not a common manifestation of the disease.

Choice E Reason:

Central vision loss is correct. Visual disturbances, including central vision loss, blurred vision, double vision, or optic neuritis, are common symptoms of multiple sclerosis. Optic neuritis, inflammation of the optic nerve, is a frequent manifestation of MS that can lead to temporary or permanent central vision loss.

A. Typical pneumonia B. Chemical pneumonitis C. Atypical pneumonia D. Aspiration pneumonia

Correct Answer is A

Explanation

Choice A Reason:

Typical pneumonia is correct. Streptococcus pneumoniae is a common bacterial pathogen that causes typical pneumonia, also known as community-acquired pneumonia (CAP). Typical pneumonia is characterized by an acute onset of symptoms such as fever, productive cough with purulent sputum, chest pain, and difficulty breathing. Streptococcus pneumoniae is one of the most common causes of typical pneumonia, especially in community settings.

Choice B Reason:

Chemical pneumonitis is incorrect. chemical pneumonitis, refers to inflammation of the lung tissue caused by inhalation or aspiration of toxic chemicals, gases, or gastric contents. It is not caused by Streptococcus pneumoniae.

Choice C Reason:

Atypical pneumonia is incorrect. Atypical pneumonia, refers to pneumonia caused by atypical pathogens such as Mycoplasma pneumoniae, Chlamydophila pneumoniae, and Legionella pneumophila. Atypical pneumonia typically presents with milder symptoms compared to typical pneumonia and may not respond to traditional antibiotics used for typical bacterial pneumonia.

Choice D Reason:

Aspiration pneumonia. Aspiration pneumonia, occurs when foreign material, such as food, saliva, or gastric contents, is aspirated into the lungs, leading to inflammation and infection. While Streptococcus pneumoniae can cause pneumonia in the context of aspiration, it is more commonly associated with typical pneumonia acquired through inhalation of respiratory droplets containing the bacteria.

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A nurse in the emergency department is assessing a client who was brought in by a neighbor after falling down suddenly while walking. Which of the following assessments are the priority for the nurse to complete?(Select All that Apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is ["B","C","E"]

Explanation

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Correct Answer is A

Explanation

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