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 ["A","B","C","D","E","F"]

Explanation

Choice A Reason:

Refraining from climbing ladders is appropriate. Climbing ladders involves a risk of falling, which can be particularly hazardous for individuals with epilepsy. Seizures can occur unexpectedly and may cause loss of muscle control or consciousness, increasing the risk of falls from heights such as ladders. Falling from a ladder during a seizure can result in serious injuries, including head trauma, fractures, or other injuries from impact. Advising the client to refrain from climbing ladders helps mitigate the risk of falls and associated injuries during a seizure episode, promoting their safety and well-being.

Choice B Reason:

Do not go swimming without a partner is inappropriate. Swimming alone can be dangerous for individuals with epilepsy as they may be at risk of drowning if they experience a seizure while in the water. Having a swimming partner can provide assistance and ensure safety in case of a seizure.

Choice C Reason:

Refraining from driving unless seizure-free for 3 months is appropriate. Driving restrictions are often recommended for individuals with epilepsy to minimize the risk of accidents caused by seizures. Many jurisdictions require individuals with epilepsy to be seizure-free for a certain period, typically around 3 to 6 months, before resuming driving.

Choice D Reason:

Avoiding using power tools is appropriate. Operating power tools or machinery can be hazardous if a seizure occurs, potentially leading to serious injuries. Therefore, individuals with epilepsy should avoid using power tools to reduce the risk of accidents during a seizure.

Choice E Reason:

Placing client on the floor when having a seizure is appropriate. Placing the client on the floor during a seizure helps prevent injury from falls. It is safer to have the individual lie down on a flat surface to reduce the risk of head injury or other trauma during the seizure.

Choice F Reason:

Placing client on their back when they are recovering from a seizure appropriate. Placing the client on their back after a seizure helps maintain an open airway and facilitates recovery. This position allows for proper breathing and circulation while monitoring the individual's condition.

A. Keep lights turned to medium level in the evening. B. Maintain the head of the bed between 30 and 45°. C. Administer hypotonic intravenous solutions. D. Reposition the client every shift.

Correct Answer is B

Explanation

Choice A Reason:

Keeping lights turned to medium level in the evening is incorrect. This intervention is aimed at reducing environmental stimuli, which may be appropriate for some patients with neurological conditions to minimize sensory overload and promote rest. However, it is not a specific intervention for preventing cerebral aneurysm rupture.

Choice B Reason:

Maintaining the head of the bed between 30 and 45° is correct. Keeping the head of the bed elevated can help reduce intracranial pressure and decrease the risk of cerebral aneurysm rupture or rebleeding in patients with aneurysmal subarachnoid hemorrhage. This position promotes venous drainage from the brain and helps prevent increases in intracranial pressure.

Choice C Reason:

Administering hypotonic intravenous solutions is incorrect. Hypotonic intravenous solutions have a lower osmolarity than blood plasma and can lead to cerebral edema, which may exacerbate intracranial pressure and increase the risk of cerebral aneurysm rupture. Isotonic solutions, such as normal saline (0.9% NaCl) or lactated Ringer's solution, are typically preferred for fluid resuscitation and maintenance in patients at risk of cerebral aneurysm rupture.

Choice D Reason:

Reposition the client every shift is incorrect. Repositioning the client every shift helps prevent complications associated with immobility, such as pressure ulcers, pneumonia, and venous thromboembolism. While important for overall patient care, repositioning alone does not directly address the risk of cerebral aneurysm rupture.

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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

A nurse is providing discharge instructions to a client who has epilepsy. Which of the following instructions should be included in the nurse's teaching? (Select All that Apply.)

Correct Answer is ["A","B","C","D","E","F"]

Explanation

A nurse is providing care for a client who is at risk of cerebral aneurysm rupture. Which of the following interventions should the nurse include in the care plan?

Correct Answer is B

Explanation

A nurse is caring for a client who presents to the hospital with manifestations of a thoracic injury. Which of the following diagnostic tools would the nurse anticipate the health care provider to order? (Select all that apply.) (Select All that Apply.)

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Which of the following are manifestations of obstructive sleep apnea? (Select all that apply.) (Select All that Apply.)

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A nurse is caring for an older adult client in the emergency department who sustained a head injury due to a fall. Which of the following are common reasons for head injuries in older adults? (Select All that Apply.)

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.)

A nurse is caring for a client who has a cerebral aneurysm. In the event of a ruptured cerebral aneurysm, which of the following manifestations would be present in the client? (Select All that Apply.)