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A nurse is conducting a primary survey of a client who has sustained life-threatening injuries due to a motor-vehicle crash. Identify the sequence of actions the nurse should take.

(Move the actions into the box on the right, placing them in the selected order of performance. Use all the steps.)

Determine effectiveness of ventilator efforts.

Remove clothing for a thorough assessment.

Open the airway using a jaw-thrust maneuver.

Perform a Glasgow Coma Scale assessment.

Control any external bleeding.

Answer and Explanation

The Correct Answer is C,A,D,B,E

The correct order is C,A,D,B,E.

C. Open the airway using a jaw-thrust maneuver.

This is the first priority since maintaining a clear airway is critical for the client’s survival.

A. Determine effectiveness of ventilatory efforts.

After ensuring the airway is open, assess the client’s breathing and whether they are ventilating effectively.

D. Perform a Glasgow Coma Scale assessment.

This step evaluates the client’s neurological status to determine their level of consciousness and identify any brain injuries.

B. Remove clothing for a thorough assessment.

To expose the client for a comprehensive physical examination and assess any injuries.

E. Control any external bleeding.

As part of circulation management, identify and stop any significant bleeding to prevent shock. This step addresses the "C" in ABCDE.

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Correct Answer is C

Explanation

A. This statement suggests a delusion or hallucination, which are common symptoms of some mental disorders, but it does not specifically suggest an inability to process new information.
B. This statement suggests paranoia, which is a common symptom of some mental disorders, but it does not specifically suggest an inability to process new information.
C. This statement suggests difficulty with memory, which is a cognitive function that is related to the ability to process new information.
D. This statement suggests a persistent negative mood, which is a symptom of some mental disorders, but it does not specifically suggest an inability to process new information.

A. Brain trauma and injury B. Bone loss and osteoporosis C. Liver and pancreatic disease D. Heart disease and stroke

Correct Answer is D

Explanation

A. While methamphetamine use can lead to risky behaviors that may increase the risk of injury, it is not directly associated with brain trauma and injury.
B. Methamphetamine use is not directly associated with bone loss and osteoporosis.
C. Methamphetamine use is not directly associated with liver and pancreatic disease.
D. Methamphetamine use can lead to blood vessel constriction and spasming, which can increase the risk of heart disease and stroke.

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A nurse is conducting a primary survey of a client who has sustained life-threatening injuries due to a motor-vehicle crash. Identify the sequence of actions the nurse should take. (Move the actions into the box on the right, placing them in the selected order of performance. Use all the steps.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has a mental disorder. Which of the following statements by the client suggests the inability to process new information?

Correct Answer is C

Explanation

A nurse is caring for a client who regularly uses methamphetamine and is experiencing blood vessel constriction and spasming. The nurse should identify that the client is at high risk for developing which of the following conditions?

Correct Answer is D

Explanation

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A nurse is conducting a primary survey of a client who has sustained life-threatening injuries due to a motor-vehicle crash. Identify the sequence of actions the nurse should take.

(Move the actions into the box on the right, placing them in the selected order of performance. Use all the steps.)