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 D
Explanation
A. Specific gravity changes relate to kidney function and hydration status, not directly to right-sided heart failure.
B. Heparin levels are related to anticoagulation therapy, not heart failure status.
C. BNP levels decrease when heart failure improves; decreased BNP is not expected in acute heart failure.
D. BNP is released in response to ventricular stretch and volume overload; it increases in acute heart failure as the heart struggles to manage fluid overload.
Correct Answer is A
Explanation
A. Viral meningitis is typically self-limiting and patients usually recover fully without specific antiviral treatment.
B. Antibiotics are not effective against viral infections and are not indicated.
C. Viral meningitis is caused by viruses, not bacteria.
D. Viral meningitis is generally less severe than bacterial meningitis and rarely life-threatening.
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