A nurse is caring for a client who has had a traumatic fall. Which of the following interventions should the nurse implement first?

Administer acetaminophen by mouth for pain control

Perform a thorough health history

Prepare for a STAT non-contrast CT scan

Insert an indwelling urinary catheter to monitor urine output

Answer and Explanation

The Correct Answer is C

A. Administer acetaminophen by mouth for pain control: While pain management is important, it is not the priority intervention in this situation. Administering acetaminophen for pain control can be done after the client's condition has been assessed and any potential serious injuries, such as head trauma, have been addressed.

B. Perform a thorough health history: Obtaining a health history is essential for understanding the client's baseline health status and any pre-existing conditions that may affect their current condition. However, in the acute phase following a traumatic fall, the priority is to assess and manage any potential life-threatening injuries.

C. Prepare for a STAT non-contrast CT scan: This is the correct answer. In cases of traumatic falls, particularly when there is concern for head injury or intracranial bleeding, obtaining a non-contrast CT scan of the head is a priority. This imaging study helps identify any intracranial injuries such as hemorrhage or skull fractures, allowing for prompt intervention if necessary.

D. Insert an indwelling urinary catheter to monitor urine output: Monitoring urine output is important for assessing renal function, but it is not the priority intervention in the immediate aftermath of a traumatic fall. The focus initially should be on assessing and managing potential life-threatening injuries, particularly those related to head trauma.

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Correct Answer is B

Explanation

B. Provide opportunities for education and continually evaluate the client's preferences and goals for care:
This is the most effective intervention. Providing education and involving the client (to the extent possible) in decision-making helps reduce anxiety and build trust. Even though individuals with Alzheimer's disease may have limited memory and cognitive abilities, ongoing communication about the transition and individualized care plans can help ease the process. Additionally, continuously evaluating the client's preferences and goals ensures that the care plan remains person-centered and aligns with their needs, helping to minimize relocation stress.

A. Colchicine B. Acetaminophen C. Indomethacin D. Amiodarone E. Nitroglycerine

Correct Answer is ["A","C"]

Explanation

A. Colchicine:

Colchicine is commonly used in the treatment of pericarditis, especially in cases of recurrent or refractory pericarditis.

It helps reduce inflammation and alleviate symptoms by inhibiting the migration of neutrophils to the inflamed pericardium.

Colchicine is often used in conjunction with nonsteroidal anti-inflammatory drugs (NSAIDs) or corticosteroids for the management of pericarditis.

B. Acetaminophen:

Acetaminophen is a pain reliever and fever reducer commonly used to manage mild to moderate pain associated with various conditions, including pericarditis.

While acetaminophen may provide symptomatic relief, it is not typically considered a primary treatment for pericarditis, especially in cases of severe or recurrent pericarditis.

C. Indomethacin:

Indomethacin is a nonsteroidal anti-inflammatory drug (NSAID) that can help reduce inflammation and relieve pain associated with pericarditis.

NSAIDs are often used as first-line therapy for acute pericarditis to alleviate symptoms such as chest pain and fever.

However, caution should be exercised when using NSAIDs in certain populations, such as older adults or those with preexisting gastrointestinal or renal conditions.

D. Amiodarone:

Amiodarone is an antiarrhythmic medication used to treat various types of arrhythmias, including ventricular arrhythmias and atrial fibrillation.

While pericarditis may lead to certain arrhythmias, such as atrial fibrillation, amiodarone is not a first-line treatment for pericarditis itself.

However, it may be used in cases where pericarditis is complicated by arrhythmias or concomitant cardiac conditions.

E. Nitroglycerine:

Nitroglycerine is a vasodilator medication commonly used to treat angina and heart failure.

While pericarditis may cause chest pain similar to angina, nitroglycerine is not typically used as a primary treatment for pericarditis.

In fact, nitroglycerine may exacerbate symptoms of pericarditis by causing venodilation and increasing cardiac preload.

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A nurse is caring for a client who has had a traumatic fall. Which of the following interventions should the nurse implement first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is ["A","C"]

Explanation

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