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

A. "Blood flow is altered and causes blood to pool in the legs." This statement inaccurately describes venous insufficiency rather than peripheral arterial disease (PAD). In PAD, blood flow is reduced or obstructed due to atherosclerosis, leading to inadequate oxygen supply to tissues rather than pooling of blood in the legs.

B. "Blood flow is altered due to atherosclerosis affecting the tissues' ability to receive oxygen-rich blood." This statement correctly explains the underlying pathology of peripheral arterial disease (PAD). Atherosclerosis, characterized by the buildup of plaque in the arteries, narrows or blocks blood flow, impairing the delivery of oxygen-rich blood to the tissues. This can result in symptoms such as pain, cramping, and tissue damage, especially during activity when oxygen demand increases.

C. "Blood flow is altered due to incompetent valves causing increased venous pressure." This statement describes venous insufficiency rather than PAD. In venous insufficiency, faulty valves in the veins result in increased venous pressure, leading to symptoms such as swelling, heaviness, and varicose veins, but it does not involve arterial obstruction as seen in PAD.

D. "Blood flow is altered due to excessive stretching of the ventricles impairing the heart to contract." This statement describes a condition related to the heart's function rather than peripheral arterial disease. Excessive stretching of the ventricles may occur in conditions such as heart failure, but it does not directly affect blood flow in the peripheral arteries as seen in PAD.

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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