The client is brought to the ER after falling off a roof and landing on his back. A T4 spinal fracture is diagnosed. The client's blood pressure is 74/40 mmHg, pulse is 55/min, and skin is pink and dry. What of the following nursing actions is a priority?

Determine if blood is present in urine

Perform a neurological assessment

Administer IV normal saline

Perform a 12-lead electrocardiogram

Answer and Explanation

The Correct Answer is C

Choice A rationale: Although important to assess for potential kidney injury, addressing hypotension due to potential spinal shock takes priority.

Choice B rationale: Important for determining any neurological deficits, but addressing hypotension is the initial priority.

Choice C rationale: Hypotension indicates potential spinal shock or hemorrhagic shock, and fluid resuscitation is the immediate priority to stabilize the client's blood pressure.

Choice D rationale: While important for assessing cardiac status, addressing hypotension takes precedence to stabilize the client's condition.

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Correct Answer is C

Explanation

Choice A rationale: This symptom typically indicates secondary syphilis, not gonorrhea.

Choice B rationale: Warts on the genitals suggest a different sexually transmitted infection caused by HPV, not gonorrhea.

Choice C rationale: A discharge from the penis is a common symptom of gonorrhea and often prompts individuals to seek medical attention.

Choice D rationale: While discomfort can be associated with gonorrhea, the primary presenting symptom often involves discharge rather than specific lesions.

A. Biopsy B. Urea breath test C. Endoscopy D. Computed tomography (CT) scan

Correct Answer is D

Explanation

Choice A rationale: Biopsy during an endoscopy can help confirm the presence of duodenal ulcers by analyzing tissue samples.

Choice B rationale: Urea breath test is used to detect the presence of Helicobacter pylori, a bacterium associated with duodenal ulcers.

Choice C rationale: Endoscopy is a standard procedure for diagnosing duodenal ulcers by directly visualizing the upper gastrointestinal tract.

Choice D rationale: While a CT scan can be useful in some cases, it's less commonly used for diagnosing duodenal ulcers compared to other diagnostic methods like endoscopy,

biopsy, or urea breath test.

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The client is brought to the ER after falling off a roof and landing on his back. A T4 spinal fracture is diagnosed. The client's blood pressure is 74/40 mmHg, pulse is 55/min, and skin is pink and dry. What of the following nursing actions is a priority?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Nurse Lily is assessing a male client diagnosed with gonorrhea. Which symptom most likely prompted the client to seek medical attention?

Correct Answer is C

Explanation

A client tells the nurse, "I have intense stomach pain for 3 hours after eating." On assessment the nurse finds abdominal pain and tenderness of the abdomen. The nurse suspects duodenal ulcers in the client. Which diagnostic procedure does the primary health-care provider least likely recommend?

Correct Answer is D

Explanation

Which assessment finding in a 36-yr-old patient is most indicative of a need for further evaluation?

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