Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is caring for a client who has had a traumatic fall. Which of the following interventions should the nurse implement first?
A. Administer acetaminophen by mouth for pain control
Administer acetaminophen by mouth for pain control: While pain management is important, it is not the priority intervention in this situation. Administering acetaminophen for pain control can be done after the client's condition has been assessed and any potential serious injuries, such as head trauma, have been addressed.
B. Perform a thorough health history
Perform a thorough health history: Obtaining a health history is essential for understanding the client's baseline health status and any pre-existing conditions that may affect their current condition. However, in the acute phase following a traumatic fall, the priority is to assess and manage any potential life-threatening injuries.
C. Prepare for a STAT non-contrast CT scan
Prepare for a STAT non-contrast CT scan: This is the correct answer. In cases of traumatic falls, particularly when there is concern for head injury or intracranial bleeding, obtaining a non-contrast CT scan of the head is a priority. This imaging study helps identify any intracranial injuries such as hemorrhage or skull fractures, allowing for prompt intervention if necessary.
D. Insert an indwelling urinary catheter to monitor urine output
Insert an indwelling urinary catheter to monitor urine output: Monitoring urine output is important for assessing renal function, but it is not the priority intervention in the immediate aftermath of a traumatic fall. The focus initially should be on assessing and managing potential life-threatening injuries, particularly those related to head trauma.
This question is an excerpt from Nurse Dive's nursing test bank - Ati Med Surg Proctored Exam 1 2024. Take the full exam now
Full Explanation
A. Administer acetaminophen by mouth for pain control: While pain management is important, it is not the priority intervention in this situation. Administering acetaminophen for pain control can be done after the client's condition has been assessed and any potential serious injuries, such as head trauma, have been addressed.
B. Perform a thorough health history: Obtaining a health history is essential for understanding the client's baseline health status and any pre-existing conditions that may affect their current condition. However, in the acute phase following a traumatic fall, the priority is to assess and manage any potential life-threatening injuries.
C. Prepare for a STAT non-contrast CT scan: This is the correct answer. In cases of traumatic falls, particularly when there is concern for head injury or intracranial bleeding, obtaining a non-contrast CT scan of the head is a priority. This imaging study helps identify any intracranial injuries such as hemorrhage or skull fractures, allowing for prompt intervention if necessary.
D. Insert an indwelling urinary catheter to monitor urine output: Monitoring urine output is important for assessing renal function, but it is not the priority intervention in the immediate aftermath of a traumatic fall. The focus initially should be on assessing and managing potential life-threatening injuries, particularly those related to head trauma.
Similar Questions
A nurse is reinforcing teaching to a group of nursing students about causes of traumatic brain injuries (TBIs). Which of the following should the nurse include in the teaching? (Select All that Apply.)
A. Falls
A) Falls: Falls are a leading cause of traumatic brain injuries (TBIs) across all age groups, especially among older adults and young children. Falls can occur due to various factors such as slipping, tripping, or accidents from heights.
B. Violence
B) Violence: Acts of violence, including assaults, gunshot wounds, and domestic abuse, are significant contributors to TBIs. These traumatic events can result in head injuries with varying degrees of severity, depending on the force and nature of the trauma.
C. Sports-related injuries
C) Sports-related injuries: Participation in contact sports or activities with a risk of collision or impact, such as football, soccer, or cycling, can lead to TBIs. Athletes may experience concussions or more severe head injuries during games or practice sessions.
D. Working as a firefighter
D) Working as a firefighter: While occupations like firefighting can expose individuals to hazardous situations, including fires and building collapses, they are not typically cited as primary causes of TBIs. However, firefighters may face head injury risks while performing their duties, especially during rescue operations or structural collapses.
E. Working in a factory
E) Working in a factory: While accidents in industrial settings can lead to various injuries, including head trauma, they are not among the primary causes of TBIs. However, workers in factories or industrial environments may face risks associated with machinery accidents, falling objects, or workplace incidents.
Full Explanation
Answer: A, B, and C
Rationale: A) Falls: Falls are a leading cause of traumatic brain injuries (TBIs) across all age groups, especially among older adults and young children. Falls can occur due to various factors such as slipping, tripping, or accidents from heights.
B) Violence: Acts of violence, including assaults, gunshot wounds, and domestic abuse, are significant contributors to TBIs. These traumatic events can result in head injuries with varying degrees of severity, depending on the force and nature of the trauma.
C) Sports-related injuries: Participation in contact sports or activities with a risk of collision or impact, such as football, soccer, or cycling, can lead to TBIs. Athletes may experience concussions or more severe head injuries during games or practice sessions.
D) Working as a firefighter: While occupations like firefighting can expose individuals to hazardous situations, including fires and building collapses, they are not typically cited as primary causes of TBIs. However, firefighters may face head injury risks while performing their duties, especially during rescue operations or structural collapses.
E) Working in a factory: While accidents in industrial settings can lead to various injuries, including head trauma, they are not among the primary causes of TBIs. However, workers in factories or industrial environments may face risks associated with machinery accidents, falling objects, or workplace incidents.
A nurse is assessing a client who has Meniere’s disease. Which of the following manifestations should the nurse expect?
A. Severe myopia
Severe myopia: Severe myopia, or nearsightedness, is not a typical manifestation of Meniere's disease. Meniere's disease primarily affects the inner ear and is characterized by symptoms related to balance and hearing rather than vision.
B. Vertigo
Vertigo: Meniere's disease is a disorder of the inner ear that causes episodes of vertigo, which is a sensation of spinning or dizziness. Vertigo is a hallmark symptom of Meniere's disease and is often accompanied by nausea, vomiting, and a feeling of fullness or pressure in the affected ear.
C. Anosmia
Anosmia: Anosmia refers to a loss of the sense of smell and is not typically associated with Meniere's disease. Meniere's disease primarily affects the vestibular system (balance) and auditory system (hearing) rather than the sense of smell.
D. Photopsia
Photopsia: Photopsia refers to the perception of flashes of light in the visual field and is not a typical manifestation of Meniere's disease. Meniere's disease primarily affects the inner ear and is not directly related to visual disturbances.
Full Explanation
A. Severe myopia: Severe myopia, or nearsightedness, is not a typical manifestation of Meniere's disease. Meniere's disease primarily affects the inner ear and is characterized by symptoms related to balance and hearing rather than vision.
B. Vertigo: Meniere's disease is a disorder of the inner ear that causes episodes of vertigo, which is a sensation of spinning or dizziness. Vertigo is a hallmark symptom of Meniere's disease and is often accompanied by nausea, vomiting, and a feeling of fullness or pressure in the affected ear.
C. Anosmia: Anosmia refers to a loss of the sense of smell and is not typically associated with Meniere's disease. Meniere's disease primarily affects the vestibular system (balance) and auditory system (hearing) rather than the sense of smell.
D. Photopsia: Photopsia refers to the perception of flashes of light in the visual field and is not a typical manifestation of Meniere's disease. Meniere's disease primarily affects the inner ear and is not directly related to visual disturbances.
A nurse is assessing a client who is experiencing a change in vision. Which of the following statements indicates that the client might be developing cataracts?
A. "My vision is blurry and objects are hazy."
Severe myopia: Severe myopia refers to nearsightedness and is not typically associated with Meniere's disease. Myopia affects vision but is unrelated to the characteristic symptoms of Meniere's disease.
B. "l can't see anything in the middle part of my eyes."
Vertigo: Vertigo is a hallmark symptom of Meniere's disease. It is characterized by a sensation of spinning or dizziness, often accompanied by nausea, vomiting, and imbalance. Vertigo episodes in Meniere's disease can be severe and debilitating, significantly impacting the individual's quality of life.
C. "There are dark spots moving around in my eye."
Anosmia: Anosmia refers to a loss of sense of smell and is not a typical manifestation of Meniere's disease. Meniere's disease primarily affects the inner ear and is characterized by symptoms related to vestibular dysfunction, such as vertigo, rather than olfactory disturbances.
D. "l can't see objects from the sides of my eyes."
Photopsia: Photopsia refers to the perception of flashing lights or visual disturbances and is not a characteristic manifestation of Meniere's disease. Visual disturbances may occur in certain conditions affecting the eyes or visual pathways but are not typically associated with Meniere's disease, which primarily affects the inner ear and vestibular system.
Full Explanation
A. Severe myopia: Severe myopia refers to nearsightedness and is not typically associated with Meniere's disease. Myopia affects vision but is unrelated to the characteristic symptoms of Meniere's disease.
B. Vertigo: Vertigo is a hallmark symptom of Meniere's disease. It is characterized by a sensation of spinning or dizziness, often accompanied by nausea, vomiting, and imbalance. Vertigo episodes in Meniere's disease can be severe and debilitating, significantly impacting the individual's quality of life.
C. Anosmia: Anosmia refers to a loss of sense of smell and is not a typical manifestation of Meniere's disease. Meniere's disease primarily affects the inner ear and is characterized by symptoms related to vestibular dysfunction, such as vertigo, rather than olfactory disturbances.
D. Photopsia: Photopsia refers to the perception of flashing lights or visual disturbances and is not a characteristic manifestation of Meniere's disease. Visual disturbances may occur in certain conditions affecting the eyes or visual pathways but are not typically associated with Meniere's disease, which primarily affects the inner ear and vestibular system.