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 B

Explanation

A. Palpation may alter bowel sounds, making auscultation after palpation less accurate.
B. Auscultation should be performed before percussion or palpation to prevent interference with the sounds.
C. Checking for kidney tenderness is important but does not affect the timing of auscultating bowel sounds.
D. Inspection should be done before auscultation to assess for any obvious abnormalities before listening for bowel sounds.

A. place the arm so that the brachial artery is at waist level. B. chat with the patient to reduce any anxiety in the patient. C. request that the patient put feet flat on the floor. D. position the patient so that the arm is level with the shoulder.

Correct Answer is C

Explanation

A. The brachial artery should be at heart level, not waist level, to ensure accurate blood pressure readings.
B. While chatting with the patient may help reduce anxiety, it is not directly related to positioning for accurate blood pressure measurement.
C. Having the patient place their feet flat on the floor ensures proper positioning and helps prevent any interference with blood pressure readings.
D. The arm should be at heart level, not at the shoulder, for accurate readings.

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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 checking a client's bowel sounds. At which of the following times should the nurse auscultate the client's abdomen?

Correct Answer is B

Explanation

The nurse taking a blood pressure should:

Correct Answer is C

Explanation

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