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Exhibits

The nurse inspects the airway. There is no visible trauma, and the airway appears to be patent. What other assessment items are included in the primary survey? Select all that apply.

Neurological status

Circulation

Current medications

Allergies

Exposure

Ventilation

Answer and Explanation

Correct Answer : A,B,E

A. Neurological status: Assessing the neurological status is crucial in the primary survey to

determine the client's level of consciousness, pupil reactions, and response to stimuli. This helps in identifying any potential brain injury or neurological deficits resulting from the fall.

B. Circulation: Evaluating circulation involves assessing the client's heart rate, blood pressure, and peripheral perfusion. In this scenario, the client's heart rate and blood pressure are provided in the nurse's notes, indicating the need to assess circulation as part of the primary survey.

C. Current medications: While important for the overall assessment and care of the client, assessing current medications is typically part of the secondary survey rather than the primary survey. The primary survey focuses on immediate life-threatening conditions.

D. Allergies: While allergies are essential information for the client's overall care, they are typically addressed during the secondary survey or during the history-taking process rather than as part of the primary survey.

E. Exposure: Assessing exposure involves ensuring the client is adequately covered and protected from environmental factors, especially in trauma situations where there may be significant blood loss or risk of hypothermia. This includes removing clothing to assess for additional injuries or bleeding.

F. Ventilation: While ventilation is crucial for assessing the client's respiratory status, including respiratory rate and effort, it is typically part of the primary survey rather than the primary survey itself. Assessing ventilation helps determine if the client is adequately breathing and oxygenating.

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Correct Answer is C

Explanation

A. Encouraging the client to participate in a team sport may be overwhelming and unrealistic given the client's current level of depression and lack of activity. Starting with smaller, more achievable goals is essential in the initial stages of treatment.

B. Helping the client develop a list of daily affirmations is a positive intervention for promoting self-esteem, but it may not address the immediate need for increasing activity levels or engagement in meaningful activities.

C. Assisting the client in identifying goals for the day is the most important intervention at this stage. Setting achievable daily goals can help the client regain a sense of purpose and motivation. These goals should be realistic and tailored to the client's current abilities and interests.

D. Scheduling the client for a group focusing on self-esteem is beneficial, but it may not directly address the client's need for increased activity and engagement in meaningful daily activities.
Goals related to self-esteem can be incorporated into the client's plan of care but should be part of a comprehensive approach to treatment.

Correct Answer is ["1.8"]

Explanation

Steps to solve:

Convert the client's weight from pounds to kilograms:
- Weight (kg) = Weight (pounds) / 2.20462
- Weight (kg) = 132 pounds / 2.20462 ≈ 59.87 kg (round to nearest tenth for medication calculation)
Calculate the total dantrolene dosage based on the prescribed dosage per kilogram:

- Dosage (mg) = Weight (kg) x Dosage per kg
- Dosage (mg) = 59.87 kg x 1.5 mg/kg
- Dosage (mg) ≈ 89.8 (round to nearest tenth)

Determine the concentration of dantrolene after reconstitution:

Concentration = 50 mg/mL (given on the vial label)

Calculate the volume of the solution to administer:

- Volume (mL) = Dosage (mg) / Concentration (mg/mL)
- Volume (mL) = 89.8 mg / 50 mg/mL
- Volume (mL) ≈ 1.79 mL (round to one decimal place)= 1.8mL

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Exhibits The nurse inspects the airway. There is no visible trauma, and the airway appears to be patent. What other assessment items are included in the primary survey? Select all that apply.

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Naxlex Comprehensive Predictor Exams

Correct Answer is C

Explanation

Correct Answer is ["1.8"]

Explanation

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Exhibits

The nurse inspects the airway. There is no visible trauma, and the airway appears to be patent. What other assessment items are included in the primary survey? Select all that apply.