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. Decerebrate posturing is characterized by extension and rigidity of the arms and legs, typically indicating damage to the midbrain or pons. It reflects severe brain injury.
B. Tonic-clonic seizures involve rhythmic muscle contractions but are not posturing.
C. Involuntary twisting and repetitive movements describe dystonia or chorea, not decerebrate posturing.
D. Uncontrolled jerking movements describe myoclonus or seizures, not decerebrate posturing.
Correct Answer is D
Explanation
A. Numerical Rating Scale is used to assess pain intensity, not consciousness.
B. Wong-Baker FACES is also a pain assessment tool, mainly for children.
C. Visual Analog Scale measures subjective pain levels.
D. Glasgow Coma Scale (GCS) is the standard tool used to assess a patient’s level of consciousness, evaluating eye opening, verbal response, and motor response.
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.