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

Answer and Explanation

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.

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Correct Answer is A

Explanation

Choice A rationale
Cushing’s Triad, which includes bradycardia (low heart rate), irregular respiration, and widened pulse pressure, is a nervous system response that could prevent brainstem ischemia. Brainstem ischemia is a condition where there is insufficient blood flow to the brainstem, which can lead to cell death.
Choice B rationale

While tachycardia (high heart rate) is a serious condition, it is not typically prevented by Cushing’s Triad.
Choice C rationale
Agonal breathing, which is characterized by gasping, labored breathing, particularly when lying flat, is not typically prevented by Cushing’s Triad.
Choice D rationale
Chest pain is not typically prevented by Cushing’s Triad. Cushing’s Triad is a response to increased intracranial pressure, not a cardiac condition.

A. People who are in their 30s B. People who play contact sports C. People who abstain from alcohol D. People who live in rural areas .

Correct Answer is B

Explanation

Choice A rationale
While traumatic brain injuries (TBIs) can occur at any age, people in their 30s are not at the highest risk. Other factors, such as participation in high-risk activities or certain occupations, can increase the risk of TBI, but age alone in this group does not confer a higher risk.
Choice B rationale
People who play contact sports are at a higher risk of sustaining a TBI. Contact sports such as football, boxing, and hockey have a high incidence of TBIs, including concussions.
Choice C rationale
Abstaining from alcohol does not increase the risk of TBI. In fact, alcohol use is a risk factor for TBI, as it can increase the likelihood of falls, car accidents, and other events that can cause TBI1112.
Choice D rationale
Living in rural areas does not inherently increase the risk of TBI. However, certain factors associated with rural living, such as increased travel distances and limited access to trauma

care, can contribute to the severity of a TBI once it occurs. Subarachnoid hemorrhageSubarachnoid hemorrhage Explore

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is gathering neurological data on a patient with a neurological injury and observes signs indicative of Cushing’s Triad. The nurse understands that Cushing’s Triad is a nervous system response that could prevent which of the following conditions?

Correct Answer is A

Explanation

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Correct Answer is B

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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?