Nokea
Spinal precautions are ordered for the client who sustained a neck injury during an MVA. The client has yet to be cleared that there is no cervical fracture. Which action is the nurse’s priority when receiving the client in the ED?
- A. Assessing the client using the Glasgow Coma Scale (GCS)
- B. Assessing the level of sensation in the client’s extremities
- C. Checking that the cervical collar was correctly placed by EMS
- D. Applying antiembolism hose to the client’s lower extremities
Correct Answer: C
Rationale: The nurse should determine the neurological status using the GCS, but this is not the priority. The nurse should assess sensation status at intervals to determine neurological injury progression, but this is not the priority. Maintaining the correct placement of the cervical collar will keep the client’s head and neck in a neutral position and prevent further injury if a spinal fracture or SCI is present. Because ensuring that the cervical collar is correctly placed will prevent further injury, it is priority. Applying antiembolism hose is an intervention to prevent thromboembolic complications, but this is not the priority.
You may also like to solve these questions
Which intervention should the nurse implement when caring for the client diagnosed with encephalitis? Select all that apply.
- A. Turn the client every two (2) hours.
- B. Encourage the client to increase fluids.
- C. Keep the client in the supine position.
- D. Assess for deep vein thrombosis (DVT).
- E. Assess for any alterations in elimination.
Correct Answer: A,D,E
Rationale: Turning every 2 hours (A) prevents pressure ulcers, assessing DVT (D) addresses immobility risks, and monitoring elimination (E) ensures bowel/bladder function. Increased fluids (B) depend on status, and supine positioning (C) may increase ICP.
The client is in the terminal stage of ALS. Which intervention should the nurse implement?
- A. Perform passive ROM every two (2) hours.
- B. Maintain a negative nitrogen balance.
- C. Encourage a low-protein, soft-mechanical diet.
- D. Turn the client and have him cough and deep breathe every shift.
Correct Answer: A
Rationale: In terminal ALS, passive ROM every 2 hours (A) prevents contractures and maintains comfort. Negative nitrogen balance (B) is undesirable, low-protein diets (C) are not indicated, and coughing/deep breathing (D) may be infeasible.
The male client is admitted to the emergency department following a motorcycle accident. The client was not wearing a helmet and struck his head on the pavement. The nurse identifies the concept as impaired intracranial regulation. Which interventions should the emergency department nurse implement in the first five (5) minutes? Select all that apply.
- A. Stabilize the client’s neck and spine.
- B. Contact the organ procurement organization to speak with the family.
- C. Elevate the head of the bed to 70 degrees.
- D. Perform a Glasgow Coma Scale assessment.
- E. Ensure the client has a patent peripheral venous catheter in place.
- F. Check the client’s driver’s license to see if he will accept blood.
Correct Answer: A,D,E
Rationale: Stabilizing the cervical spine (A) prevents spinal injury, Glasgow Coma Scale (D) assesses neurological status, and IV access (E) prepares for interventions. Organ procurement (B) is premature, high HOB (C) risks perfusion, and checking for blood acceptance (F) is secondary.
Which instruction should the nurse include for a client taking phenytoin (Dilantin)?
- A. Brush teeth gently to prevent gum hyperplasia.
- B. Avoid grapefruit juice.
- C. Take the medication with milk.
- D. Increase dietary sodium intake.
Correct Answer: A
Rationale: Phenytoin can cause gingival hyperplasia; gentle brushing helps prevent gum complications.
The friend of an 18-year-old male client brings the client to the emergency department (ED). The client is unconscious and his breathing is slow and shallow. Which action should the nurse implement first?
- A. Ask the friend what drugs the client has been taking.
- B. Initiate an IV infusion at a keep-open rate.
- C. Call for a ventilator to be brought to the ED.
- D. Apply oxygen at 100% via nasal cannula.
Correct Answer: C
Rationale: Slow, shallow breathing in an unconscious client indicates respiratory depression, a life-threatening condition. Calling for a ventilator (C) ensures immediate airway support. Asking about drugs (A), starting an IV (B), and applying oxygen (D) follow airway management.