A patient was admitted with possible head trauma after a motor vehicle accident. The nursing implementation with the highest priority is to:

auscultate lung and abdominal sounds.

check for verbal and motor response.

monitor daily weight.

monitor intake and output.

Answer and Explanation

The Correct Answer is B

A.   While auscultating lung and abdominal sounds is important, it is not as urgent as checking neurological function in a head trauma patient.
B.   Assessing verbal and motor responses is critical to evaluate the level of consciousness and neurological function in a patient with head trauma.
C.   Monitoring daily weight is not an immediate concern for a patient with possible head trauma.
D.   Monitoring intake and output is important but not the priority compared to assessing the neurological status in head trauma patients.

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Correct Answer is A

Explanation

A. Listening to the apical pulse for one full minute provides a more accurate reading of the heart rate and rhythm, especially when the radial pulse is irregular.
B. Recording the findings on the graphic sheet is necessary, but it doesn’t address the irregularity of the pulse.
C. Taking the pulse on the other wrist does not provide the necessary information about the apical pulse.
D. Taking the pulse for one full minute on the other wrist is not necessary unless the pulse is absent on the first wrist.

A. dilation reflex. B. brisk reflex, C. accommodation. D. consensual reflex

Correct Answer is D

Explanation

A. The dilation reflex refers to pupils dilating in response to dim light, not constricting.
B. A brisk reflex is an expected response, but it does not describe the bilateral pupil constriction when light is shone in one eye.
C. Accommodation refers to the process of the eyes adjusting focus for near vision, not pupil constriction in response to light.

D. Consensual reflex is when both pupils constrict in response to light shined in either one of the eyes, indicating normal neurological function.

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A patient was admitted with possible head trauma after a motor vehicle accident. The nursing implementation with the highest priority is to:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a patient with a cardiac disease history. When measuring vital signs, the nurse finds that the radial pulse is 102 beats/min and irregular. The nurse correctly:

Correct Answer is A

Explanation

When examining a patient's pupils with a light, the nurse notes that both pupils constrict, regardless of which eye is stimulated by the light. The nurse should document that the pupils exhibit:

Correct Answer is D

Explanation

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