Which of the following would the nurse understand is correct when implementing a primary assessment for clients suffering major trauma? The primary assessment:
includes the head-to-toe anterior and posterior assessment.
priorities are continuing and ongoing but treatment will be deferred if the clients unstables
is focused on airway maintenance and ventilation effectiveness.
focuses on the ABCDs of the client to identify life threatening problems
The Correct Answer is D
A. includes the head-to-toe anterior and posterior assessment.
This describes a secondary assessment, not a primary one. The primary assessment focuses on the immediate life-threatening issues rather than a full head-to-toe examination.
B. priorities are continuing and ongoing but treatment will be deferred if the client is unstable.
In primary assessment, treatment should not be deferred in unstable clients. Immediate treatment and stabilization take priority.
C. is focused on airway maintenance and ventilation effectiveness.
As airway and ventilation are key aspects of the primary assessment (known as the "ABC" of trauma: Airway, Breathing, Circulation). However, it does not cover all of the primary assessment areas.
D. focuses on the ABCDs of the client to identify life-threatening problems.
The primary assessment is focused on identifying life-threatening problems using the ABCDs (Airway, Breathing, Circulation, Disability).
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Inspect muscle symmetry in the upper and lower extremities
While muscle symmetry is important, it only assesses muscle mass and atrophy, not motor function or coordination.
B. The RN asks the client to squeeze their hand or show 2 fingers and lift their arm off the bed
This assesses motor strength and coordination, which are key components of motor ability. Handgrip strength and upper limb movement provide important information about neurological function.
C. Check plantar response and deep tendon reflex testing bilaterally
These tests assess reflexes and neurological pathways rather than motor function and coordination.
D. Comparative cranial nerve assessments and ability to follow simple commands
While following commands assesses cognition, it does not directly evaluate muscle strength or motor ability.
Correct Answer is D
Explanation
A. includes the head-to-toe anterior and posterior assessment.
This describes a secondary assessment, not a primary one. The primary assessment focuses on the immediate life-threatening issues rather than a full head-to-toe examination.
B. priorities are continuing and ongoing but treatment will be deferred if the client is unstable.
In primary assessment, treatment should not be deferred in unstable clients. Immediate treatment and stabilization take priority.
C. is focused on airway maintenance and ventilation effectiveness.
As airway and ventilation are key aspects of the primary assessment (known as the "ABC" of trauma: Airway, Breathing, Circulation). However, it does not cover all of the primary assessment areas.
D. focuses on the ABCDs of the client to identify life-threatening problems.
The primary assessment is focused on identifying life-threatening problems using the ABCDs (Airway, Breathing, Circulation, Disability).
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