The nurse in the emergency department is caring for a client who has fallen 20 feet from a roof. While performing the primary assessment, what is the most important nursing intervention?

Remove clothing

Maintain cervical spine precaution

Perform a mental status exam

Assess for facial lacerations

Answer and Explanation

The Correct Answer is B

A. Remove clothing: While removing clothing may be necessary for a thorough assessment and treatment, maintaining cervical spine precaution takes precedence to prevent potential spinal cord injury in clients with a history of trauma, such as a fall from a significant height.

B. Maintain cervical spine precaution: Maintaining cervical spine precaution by stabilizing the cervical spine and immobilizing the neck is crucial to prevent further injury to the spinal cord in clients with a history of trauma until spinal injury is ruled out or managed.

C. Perform a mental status exam: While assessing the client's mental status is important for evaluating neurological function, it is not the first priority in a client with potential spinal cord injury following a fall.

D. Assess for facial lacerations: Assessing for facial lacerations is important for identifying and managing potential facial injuries, but it is not the first priority in the primary assessment of a client with a history of trauma and potential spinal cord injury.

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Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"B"}

Explanation

The nurse and address the clients right shoulder pain after addressing the clients drowsiness. a clients recovery can be affected by pain by inhibiting their ability to become active and involved in self-care. The goal is to provide pain relief so that the client is able to participate in the recovery and to improve the clients functional status. Assessment of paint should include intensity, quality, duration, and location.

A. Restlessness B. Amnesia C. Tachycardia D. Hypotension

Correct Answer is A

Explanation

A. Restlessness: Restlessness is a common early sign of increased intracranial pressure (ICP) in clients with traumatic brain injury. It can result from discomfort, confusion, or agitation due to pressure on the brain.

B. Amnesia: Amnesia, or memory loss, can occur with traumatic brain injury but is not specifically indicative of increased intracranial pressure.

C. Tachycardia: Tachycardia may occur in response to various factors such as pain, stress, or fever, but it is not a specific indicator of increased intracranial pressure.

D. Hypotension: Hypotension (low blood pressure) is not typically associated with increased intracranial pressure. In fact, hypertension (high blood pressure) may be a compensatory response to maintain cerebral perfusion pressure in the setting of elevated ICP.

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The nurse in the emergency department is caring for a client who has fallen 20 feet from a roof. While performing the primary assessment, what is the most important nursing intervention?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a 24-year-old client who reports a recent fall, hitting their head and right shoulder. Exhibits Complete the following sentence by using the list of options. The nurse should first address the client's dropdown followed by the client's dropdown

Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"B"}

Explanation

A nurse is caring for a client who has a traumatic brain injury. Which of the following findings should the nurse identify as an indication of increased intracranial pressure (ICP)?

Correct Answer is A

Explanation

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