Nokea
The nurse arrives at the scene of a motor-vehicle accident and the car is leaking gasoline. The client is in the driver's seat of the car complaining of not being able to move the legs. Which actions should the nurse implement? List in order of priority.
- A. Move the client safely out of the car.
- B. Assess the client for other injuries.
- C. Stabilize the client's neck.
- D. Notify the emergency medical system.
- E. Place the client in a functional anatomical position.
Correct Answer: C,B,A,D,E
Rationale: Stabilize the client’s neck (C): Prevents spinal injury. 2. Assess for other injuries (B): Identifies life-threatening issues. 3. Move the client safely (A): Removes from gasoline danger. 4. Notify EMS (D): Ensures professional help. 5. Place in anatomical position (E): Least urgent.
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The client is diagnosed with ALS. Which client problem would be most appropriate for this client?
- A. Disuse syndrome.
- B. Altered body image.
- C. Fluid and electrolyte imbalance.
- D. Alteration in pain.
Correct Answer: A
Rationale: ALS causes progressive muscle weakness, leading to disuse syndrome (A) from immobility. Body image (B) is secondary, fluid/electrolyte issues (C) are not primary, and pain (D) is less common.
The nurse is implementing interventions for the client who has increased ICP. The nurse knows that which result will occur if the increased ICP is left untreated?
- A. Displacement of brain tissue
- B. Increase in cerebral perfusion
- C. Increase in the serum pH level
- D. Leakage of cerebrospinal fluid
Correct Answer: A
Rationale: If untreated, increased ICP causes a shift in brain tissue and can result in irreversible brain damage and possibly death. ICP compresses structures within the cranium and leads to a decrease in cerebral perfusion, not increased perfusion. ICP compresses structures within the cranium and leads to acidosis; the pH level is decreased in acidosis. Leakage of CSF could occur if there were an opening in the subarachnoid space that could occur with trauma, but there is no indication that the increased ICP is due to trauma.
If the client had been unresponsive except to painful stimuli, which new assessment finding indicates that the client is improving?
- A. Pupils are fixed when stimulated with light.
- B. Pupils are unequal when stimulated with light.
- C. Client's Glasgow Coma Scale score is 12.
- D. Stroking the cheek with a swab causes swallowing.
Correct Answer: C
Rationale: A Glasgow Coma Scale score of 12 indicates improved responsiveness compared to being unresponsive except to painful stimuli, suggesting neurological improvement.
Which nursing action is priority when caring for a client with suspected brain death?
- A. Administer pain medication.
- B. Perform a neurologic assessment.
- C. Increase fluid intake.
- D. Encourage family visitation.
Correct Answer: B
Rationale: A thorough neurologic assessment is critical to confirm brain death criteria, guiding further care decisions.
A family member brings the client to the emergency department reporting that the 78-year-old father has suddenly become very confused and thinks he is living in 1942, that he has to go to war, and that someone is trying to poison him. Which question should the nurse ask the family member?
- A. Has your father been diagnosed with dementia?'
- B. What medication has your father taken today?'
- C. What have you given him that makes him think it's poison?'
- D. Does your father like to watch old movies on television?'
Correct Answer: B
Rationale: Sudden confusion and delusions suggest delirium, often medication-related. Asking about medications (B) identifies potential causes. Dementia (A) causes gradual decline, blaming poison (C) is untherapeutic, and movies (D) are irrelevant.