A young adult client is brought to the emergency department reporting a headache. The client has bruises around the face and on the upper arms. The nurse suspects the client is the victim of physical abuse. In which order should the nurse implement these interventions? (Arrange the nursing actions with the highest priority first, on top, and lowest priority last, on bottom.)

Provide a safety plan to prevent further violence.

Inspect head for trauma.

Evaluate range of motion of all joints.

Perform a neurological exam.

Answer and Explanation

The Correct Answer is B,D,C,A

Inspect head for trauma. Head injuries can be life-threatening, so the nurse must first assess for signs of skull fractures, concussions, or intracranial bleeding that could explain the headache.
Perform a neurological exam. If head trauma is suspected, a neurological exam is essential to assess for altered mental status, coordination deficits, or signs of increased intracranial pressure.
Evaluate range of motion of all joints. After ruling out life-threatening conditions, the nurse should assess for musculoskeletal injuries, fractures, or soft tissue damage from physical abuse.
Provide a safety plan to prevent further violence. Once the client is medically stable, the nurse should provide resources, assess risk for further harm, and develop a safety plan to prevent future abuse.

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Correct Answer is C

Explanation

A. Anaphylactic. Anaphylactic reactions are caused by severe allergic responses, leading to histamine release, vasodilation, and bronchoconstriction. While burns trigger an immune response, it is an inflammatory reaction rather than an allergic one.
B. Noncompensatory. The body's response to burns is compensatory, not noncompensatory. The body immediately reacts by activating the inflammatory and stress responses to maintain perfusion and initiate healing.
C. Inflammatory. A severe burn triggers an immediate and massive inflammatory response, causing capillary leakage, fluid shifts (burn shock), and immune activation. This leads to edema, hypovolemia, and increased risk of infection. The inflammatory response also activates cytokines and white blood cells to begin tissue repair.
D. Cholinergic. The cholinergic response is related to the parasympathetic nervous system, which controls rest-and-digest functions. Severe burns primarily activate the sympathetic nervous system (fight-or-flight), leading to vasoconstriction, tachycardia, and increased metabolic demands.

A. Developmental stage. B. Functional capacity. C. Age and gender. D. Medical diagnoses.

Correct Answer is B

Explanation

A. Developmental stage. While understanding the client’s psychosocial needs is important, the ability to perform daily activities and remain independent is more critical in determining the best living environment.
B. Functional capacity. The ability to perform activities of daily living (ADLs) and instrumental activities of daily living (IADLs) is the most important factor in determining the appropriate living environment. Clients with limited mobility, cognitive decline, or difficulty managing self-care may require assisted living or skilled nursing care.
C. Age and gender. Age and gender alone do not determine the need for a particular living environment. Some older adults remain independent well into their later years, while others may require assistance at a younger age due to functional decline.
D. Medical diagnoses. While medical conditions influence care needs, they do not solely determine living arrangements. A client with a chronic illness who maintains functional independence may still live at home, whereas a client with minimal medical issues but significant functional decline may require assisted care.

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Naxlex Comprehensive Predictor Exams

A nurse working in a burn unit cares for clients with complicated body system responses. Which response describes the body's initial reaction to a severe burn injury?

Correct Answer is C

Explanation

In assisting the family of an older adult client to determine the best living environment for the client, which factor is most important for the nurse to consider?

Correct Answer is B

Explanation

The nurse is visiting an older adult client who is homebound. Which finding about the client's nutritional status requires additional follow- up?

A female client was horseback riding when her horse slipped and fell on her leg, crushing but not breaking it, and resulting in a large amount of edema over the crushed area. Which pathophysiological mechanism is responsible for the edema?

The nurse is assessing the nutritional status of a group of clients in a long term care facility. Which pathophysiological process poses the highest risk for malnutrition in this population?

After reviewing the history of a group of clients, which client should the nurse identify as having the greatest risk for cancer?

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