Exhibits

Following the fluid bolus, the client is more awake and able to answer questions. What questions are appropriate for the secondary survey? Select all that apply.

Do you take any medications?

What happened before you fell?

What was your last meal?

Is it possible that you are pregnant?

Do you live with anyone?

Are you fully insured?

Answer and Explanation

Correct Answer : A,B,C,D,E

-   A) Knowing the medications the patient takes is crucial for understanding her medical history and any potential interactions with treatments that may be administered.

-   B) Understanding the events leading up to the fall can help in assessing the cause and potential injuries sustained, which is important for her current and future treatment plans.

-   C) Information about the last meal is important for anesthesia considerations, in case surgery is required, and for understanding the patient's nutritional status.
-   D) Knowing if the patient is pregnant is vital as it influences the management of her care and the urgency of certain tests, as well as the avoidance of potential harm to the fetus.
-   E) Information about cohabitants can be useful for social support and may also provide additional information about the circumstances leading to the injury.
-   F) While insurance status is a practical consideration, it is not clinically relevant to the secondary survey and immediate care of the patient. Therefore, it is not an appropriate question at this stage.

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Correct Answer is D

Explanation

A: Using a different sphygmomanometer would not address the underlying cause of the spasms, which is likely not related to the equipment itself.
B: Taking the blood pressure in the other arm may avoid the spasms temporarily, but it does not address the potential underlying medical issue causing the spasms.
C: Administering an antianxiety medication is not indicated as the spasms are not necessarily related to anxiety; they could be a sign of a physiological condition.
D: Reviewing the client's serum calcium level is the most appropriate action. The spasms described are indicative of Trousseau's sign, which is associated with hypocalcemia. Hypocalcemia can cause increased neuromuscular excitability, leading to spasms. It is important to identify and treat the underlying cause of the spasms, which in this case could be a calcium deficiency.

Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"D","dropdown-group-3":"F"}

Explanation

A. being cold: Being cold is not directly related to the symptoms described in the scenario.

The client's symptoms include dizziness, headache, burning feeling on extremities, and redness on face and extremities, but there is no mention of feeling cold.
B. dyspnea: Dyspnea, or difficulty breathing, may occur as a result of an adverse reaction such as anaphylaxis or severe cardiovascular compromise. It is a concerning symptom that warrants immediate attention and intervention.

C. shaking: Shaking is not mentioned in the client's symptoms in the scenario. While it can be a sign of distress or discomfort, it is not directly related to the symptoms of dyspnea, nausea, and headache described.
D. nausea: Nausea is a common symptom associated with adverse reactions to medications, including allergic reactions or cardiovascular events. It can contribute to the client's overall discomfort and may indicate ongoing or worsening adverse effects.
E. blood pressure 116/68 mm Hg: The client's blood pressure of 116/68 mm Hg is not

indicative of ongoing adverse reactions. While the initial blood pressure reading was low (108/46 mm Hg), it is not included as part of the ongoing symptoms described.
F. headache: Headache can be a manifestation of various adverse reactions, including allergic reactions or changes in blood pressure. It is a symptom that should be monitored closely as it can indicate ongoing or worsening complications.

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Exhibits Following the fluid bolus, the client is more awake and able to answer questions. What questions are appropriate for the secondary survey? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

An unlicensed assistive personnel (UAP) reports that a client's right hand and fingers spasm when taking the blood pressure using the same arm. After confirming the presence of the spasms, which action should the nurse take?

Correct Answer is D

Explanation

Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"D","dropdown-group-3":"F"}

Explanation

An older adult client arrives at the clinic reporting decreased strength in knees and in handgrips. Which action should the nurse include in a functional assessment of the client?

Exhibits The nurse should place the client in a position to promote

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Exhibits

Following the fluid bolus, the client is more awake and able to answer questions. What questions are appropriate for the secondary survey? Select all that apply.