A client who has a head injury is transported to the emergency department. Which assessment does the emergency department nurse perform immediately?
a. Pupil response
b. Motor function
c. Respiratory status
d. Short-term memory
C
Respiratory derangements (e.g., hypoxemia, hypercarbia, alterations in pH) can contribute to secondary brain injury in this scenario. Therefore, the important priority is assessment of respi-ratory status so that secondary brain injury conditions are avoided. The other assessments should be performed after effective respiratory functions have been established.
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In performing a pain assessment, the LPN would follow which steps?
1. Assess vital signs, status of pain, and aggravating factors. 2. Assess location, quality, and intensity on an identified scale. 3. Assess the intensity on an identified scale and record findings. 4. Assess vital signs and location, and report to the RN.
A patient tells the nurse that he is recently unemployed and has fears that he will never find another job. The nurse recognizes this patient's internal stressor as being:
1. All-or-nothing thinking. 2. Denial. 3. A catastrophic event. 4. A realistic expectation.
A person allergic to chocolate is likely to develop a migraine because:
A. histamine dilates cerebral blood vessels, which stimulates nearby pain receptors. B. histamine constricts cerebral blood vessels, which stimulates pain receptors. C. IgE constricts cerebral blood vessels, which stimulates pain receptors. D. IgE dilates cerebral blood vessels, which stimulates nearby pain receptors.
The nurse explains to a pregnant patient that the mother's prior exposure to illness and immunizations prompts the development of antibodies in the newborn in a process termed __________ immunity
Fill in the blank with the appropriate word.