A nurse is caring for a client who is unconscious following a stroke. Which of the following nursing interventions is of highest priority?
Monitor the client's electrolyte levels.
Perform passive range of motion on each extremity.
Suction saliva from the client's mouth.
Record the client's intake and output.
The Correct Answer is C
A. Monitoring electrolyte levels is important but is not as immediate as ensuring airway patency.
B. Performing passive range of motion is beneficial for mobility but does not address the immediate needs of an unconscious patient.
C. Suctioning saliva from the client's mouth is the highest priority intervention, as maintaining airway clearance is critical to prevent aspiration and ensure adequate ventilation.
D. Recording intake and output is necessary for overall assessment but is not as urgent as managing the airway.
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Correct Answer is D
Explanation
A. Standing with feet close together when lifting an object does not provide adequate support or balance, increasing the risk of injury. Proper body mechanics involve keeping feet apart for a stable base of support.
B. Putting weight on the heels when moving an object is not advised. Instead, one should keep the weight distributed over the whole foot for stability.
C. When pushing an object, stepping forward with the front foot (rather than moving it backward) helps to maintain balance and applies proper force.
D. Facing the direction of movement is a correct application of proper body mechanics, as it prevents twisting of the spine, reduces strain on the back, and promotes safe movement.
Correct Answer is B
Explanation
A. A contrecoup injury is a true injury and can be significant; stating it is not considered "true" is incorrect and indicates a lack of understanding.
B. This statement accurately describes coup and contrecoup injuries, where a coup injury occurs at the site of impact and a contrecoup injury occurs on the opposite side of the brain.
C. This statement is incorrect because a coup injury does not occur secondary to the contrecoup; they can happen simultaneously during trauma.
D. Contrecoup injuries can be just as severe as coup injuries, and the healing process varies; stating they are easier to heal from is misleading and reflects a misunderstanding.