Global Rationale Cognitive Level Analyzing Client Need Physiological Integrity

Global rationale cognitive level analyzing client

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Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 24-3 Question 7Type: SEQThe nurse witnesses a motor vehicle accident (MVA) while off duty. Upon approaching the scene, the nurse observes a victim lying on the ground after being ejected from the vehicle. Beginning with the action the nurse must first take, place the actions in the correct order. All options must be used.
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Standard Text: Click and drag the options below to move them up or down. Choice 1. Check the victim’s breathing. Choice 2. Check the victim’s pulse. Choice 3. Check the victim’s airway. Choice 4. Immobilize the victim’s spine. Choice 5. Check for responsiveness. Correct Answer: 5,4,3,1,2 Rationale 1 : After immobilization, the nurse assesses the patient’s ABCs: airway, breathing, and circulation (pulse). Rationale 2 : After immobilization, the nurse assesses the patient’s ABCs: airway, breathing, and circulation (pulse). Rationale 3 : After immobilization, the nurse assesses the patient’s ABCs: airway, breathing, and circulation (pulse). Rationale 4 : The nurse immobilizes the spine using the jaw-thrust technique to prevent further injury to the spine. Rationale 5 : In an emergency situation, the nurse first assesses the patient’s level of consciousness during the primary survey of CPR. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 24-4 Question 8Type: MCSAThe nurse is educating a patient and the family about different types of stabilization devices. Which statement by the patient indicates that the patient understands the benefit of using a halo fixation device instead of Gardner-Wells tongs? 1. “I will have less pain if I use the halo device.”2. “The halo device will allow me to get out of bed.”3. “I am less likely to get an infection with the halo device.”
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4. “The halo device does not have to stay in place as long.”Correct Answer: Rationale 1: The patient’s pain level is not affected by the type of stabilization device used.Rationale 2: A halo device does not require weights as the tongs do, thereby allowing the patient to be mobile.Rationale 3: The patient does not have a greater risk of infection with the Gardner-Wells tongs; both devices require pins inserted into the skull.Rationale 4: The time required for stabilization is not dependent on the type of stabilization device used. 2 Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 24-4
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