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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Administer naproxen: While pain management is important, naproxen may not effectively resolve the headache associated with post-lumbar puncture headache (PLPH), which is often caused by cerebrospinal fluid leakage.
B. Elevate the head of the bed to 30°: While elevating the head of the bed may provide some relief, it is not typically sufficient to resolve PLPH, which often requires more definitive interventions.
C. Check BP and call for a blood patch: PLPH is commonly treated with a blood patch, which involves injecting the patient's own blood into the epidural space to seal the puncture site and restore normal cerebrospinal fluid pressure. Checking blood pressure is important to assess for hypotension, and calling for a blood patch is the most appropriate action to address the underlying cause of the headache.
D. Darken the client's room and close the door: While creating a quiet and dim environment may help alleviate symptoms of headache, it does not address the underlying cause of PLPH and is not the most appropriate intervention in this situation.
Correct Answer is B
Explanation
A. Observe the client's ability to smile and frown: This assessment is related to cranial nerve VII (facial nerve), which controls facial expressions.
B. Instruct the client to look up and down without moving his head: Cranial nerve III (oculomotor nerve) controls eye movements, including upward and downward gaze. Asking the client to look up and down without moving the head assesses the function of this nerve.
C. Ask the client to shrug his shoulders against passive resistance: This assessment is related to cranial nerve XI (accessory nerve), which innervates the trapezius and sternocleidomastoid muscles involved in shoulder shrugging.
D. Have the client stand with eyes his closed and touch his nose: This assessment is part of the cerebellar function test and assesses coordination and proprioception but does not specifically assess cranial nerve III.
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