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 A
Explanation
Choice A rationale
Bruising over the mastoid process, also known as Battle’s sign, is a classic clinical sign of a basilar skull fracture.
Choice B rationale
Pooling of blood and edema around the eyes, or ‘raccoon eyes’, is another sign of a basilar skull fracture.
Choice C rationale
The ability to recall how the injury occurred is not directly related to the presence of a basilar skull fracture. Memory loss or confusion could be symptoms of a traumatic brain injury, but they are not specific to a basilar skull fracture.
Choice D rationale
Chvostek’s sign is a clinical sign of hypocalcemia, not a basilar skull fracture
Correct Answer is B
Explanation
Choice A rationale
While a stiff neck can be a symptom of a cerebral aneurysm, it is not a definitive sign. A stiff neck is more commonly associated with conditions like meningitis.
Choice B rationale
Most cerebral aneurysms do not cause symptoms until they rupture or become very large. Therefore, a person with a cerebral aneurysm typically will have no symptoms.
Choice C rationale
Seizures can occur if a cerebral aneurysm ruptures and causes bleeding in the brain. However, seizures are not a common symptom of unruptured cerebral aneurysms.
Choice D rationale
Nausea and vomiting can occur if a cerebral aneurysm ruptures and causes a sudden increase in intracranial pressure. However, these are not typical symptoms of an unruptured cerebral aneurysm.
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