A nurse in the emergency department is evaluating a client who was brought in by a neighbor after suddenly falling while walking.
What assessments should the nurse prioritize?
Assessing muscle strength
Checking for facial symmetry
Checking peripheral pulses
Evaluating vision changes
Checking for aphasia
Asking about smoking history
Correct Answer : A,B,D,E
Choice A rationale
Assessing muscle strength is important after a fall as it can help determine if the fall was due to muscle weakness or other neurological issues.
Choice B rationale
Checking for facial symmetry is crucial as asymmetry may indicate a stroke or other serious neurological condition.
Choice C rationale
While checking peripheral pulses is important in general, it may not be the top priority in this case unless there is a specific reason to suspect circulatory issues.
Choice D rationale
Evaluating vision changes is important as sudden vision loss or changes could indicate a serious condition such as a stroke.
Choice E rationale
Checking for aphasia, or difficulty with language, is crucial as it can be a sign of a stroke or other serious neurological condition.
Choice F rationale
Asking about smoking history may not be a priority in the immediate assessment of a patient who has just fallen.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C","D"]
Explanation
Choice A rationale
Hyponatremia, or low sodium levels, is not typically a symptom of degenerative disc disease. It can be caused by a variety of conditions, but it is not directly linked to degenerative disc disease.
Choice B rationale
Paresthesia, or abnormal sensations such as tingling or prickling, can develop with degenerative disc disease. This is due to the fact that degenerative changes can lead to nerve compression, which can cause these sensations.
Choice C rationale
Foot drop, a gait abnormality, can be a symptom of degenerative disc disease. It can occur if the disease process affects the nerves that control the muscles involved in lifting the foot.
Choice D rationale
Intermittent pain is a common symptom of degenerative disc disease. The pain can vary in intensity and may be worse with certain activities or positions.
Choice E rationale
Hyperreflexia, or overactive reflexes, is not typically a symptom of degenerative disc disease. It is more commonly associated with conditions that affect the upper motor neurons.
Correct Answer is B
Explanation
Choice A rationale
Cognitive behavioral therapy (CBT) is a type of psychological treatment that can be effective for a range of conditions, including chronic pain. However, it may not be the most suitable for acute pain management at home following a knee injury. CBT usually involves working with a trained therapist over multiple sessions, which may not be practical or immediately beneficial in this context.
Choice B rationale
Intermittent ice compress is a highly recommended non-pharmacological method for managing acute pain, especially following a knee injury. The cold temperature from the ice can help numb the area, reducing pain and inflammation. It’s a simple, cost-effective, and readily available method that can be easily applied at home.
Choice C rationale
Phototherapy, also known as light therapy, involves exposure to specific wavelengths of light using polychromatic polarised light, lasers, light-emitting diodes, fluorescent lamps, or dichroic lamps. While it has been used to treat conditions like seasonal affective disorder, skin conditions, and neonatal jaundice, its effectiveness in managing acute pain following a knee injury is not well-established.
Choice D rationale
Walking on a treadmill might not be suitable for a patient experiencing acute pain following a knee injury. Physical activity is generally beneficial for overall health and certain types of chronic pain. However, in the case of an acute knee injury, rest and immobilization are often recommended initially to allow the injured tissues to heal.
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