During admission of a patient with a severe head injury to the emergency department, the nurse places the highest priority on assessment for
Cerebrospinal fluid leakage from the ears and nose.
Presence of a neck injury.
Patency of airway
neurological status with the Glasgow coma scale
The Correct Answer is C
A. Cerebrospinal fluid leakage is important to note but not the immediate priority.
B. Assessing for neck injury is crucial but airway management takes precedence to prevent life-threatening hypoxia.
C. Ensuring airway patency is the highest priority in trauma care to maintain oxygenation and ventilation, which are vital for survival.
D. Neurological assessment with the Glasgow Coma Scale is important but comes after securing airway, breathing, and circulation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Cor pulmonale causes right-sided heart failure, leading to systemic venous congestion and dependent edema.
B. Chest pain is more commonly associated with left-sided heart issues or coronary artery disease.
C. Crackles in the lungs are signs of left-sided heart failure due to pulmonary congestion.
D. Hypotension is not a typical early sign of cor pulmonale or right-sided heart failure.
Correct Answer is B
Explanation
A. Left-sided weakness may occur with a stroke or focal brain lesion, not typically with meningitis.
B. Nuchal rigidity (stiff neck) is a hallmark sign of meningeal irritation seen in meningitis.
C. Fatigue is nonspecific and can occur in many illnesses but is not a defining feature of meningitis.
D. Chest pain is unrelated to the inflammation of the meninges.
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