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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Increase in interstitial osmotic pressure due to cellular damage. A crushing injury damages cells, leading to the release of intracellular proteins and solutes into the interstitial space. This increases interstitial osmotic pressure, drawing fluid from the blood vessels into the injured tissues, causing edema. The inflammatory response further contributes to capillary permeability and fluid leakage.
B. Decrease in interstitial pressures due to low blood pressure. Blood pressure does not directly regulate interstitial pressure in a localized trauma area. Even if systemic blood pressure were low, localized edema can still occur due to tissue damage and increased capillary permeability.
C. Increased intravascular osmotic pressure due to crushing injury. Osmotic pressure in the blood is primarily determined by plasma proteins, such as albumin. A crushing injury does not increase intravascular osmotic pressure; instead, it increases interstitial osmotic pressure, pulling fluid out of the blood vessels.
D. Increased intravascular hydrostatic pressure due to trauma. While trauma can cause localized vascular changes, hydrostatic pressure primarily affects systemic circulation. In this case, localized tissue damage and inflammation—not increased intravascular pressure—are responsible for edema formation.
Correct Answer is D
Explanation
A. Continues to take a prescribed vitamin D supplement. Vitamin D supplementation is recommended for older adults to support bone health and calcium absorption. This does not require additional follow-up.
B. Usually eats an additional serving of protein-rich foods daily. Adequate protein intake is essential for muscle maintenance and overall health in older adults. This is a positive nutritional habit and does not indicate a concern.
C. Takes 1200 mg of an over-the-counter calcium supplement daily. This is within the recommended daily intake for older adults (1,000-1,200 mg/day) to maintain bone health. Excess calcium intake should be monitored, but this amount alone does not require urgent follow-up.
D. Ate approximately 1,200 calories daily for the past two weeks. Older adults typically need at least 1,500-2,000 calories per day, depending on activity level and health conditions. A prolonged intake of only 1,200 calories per day may indicate malnutrition, unintentional weight loss, or inadequate nutrient intake, requiring further evaluation.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.
