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.
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Related Questions
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
Correct Answer is A
Explanation
Choice A rationale
A traumatic brain injury (TBI) can indeed disrupt cellular function and cause blood vessel damage. This can lead to a range of potential effects, from temporary changes in brain function to long-term complications or even death.
Choice B rationale
Damage to brain tissue from decreased pressure shock waves is not typically associated with TBI. This type of injury is more commonly associated with blast injuries, such as those caused by explosions.
Choice C rationale
While increased blood supply and edema (swelling) can occur in the area of a brain injury, they are typically responses to the injury rather than direct consequences of the TBI itself. These processes can contribute to further damage and complications.
Choice D rationale
A TBI does not typically lead to increased synaptic connections. In fact, the injury can cause loss of neurons and synapses, which can lead to long-term cognitive and functional impairments.
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