Multiple Response Grouping Item
Multiple Response Grouping Item
The Multiple Choice Grouping Item is similar to Multiple Choice Response Select All That Apply, but presented in a table form, with at least two columns and several rows.
A 20-year-old was bought to the emergency department. According to friends, the client broke up with his girlfriend 8 months ago and has been drinking every weekend and sometimes during the week. The friends report that the client fell, but cannot describe how. The client is lethargic, answers questions incoherently, points to pain to his back and neck, and smells of alcohol and urine. Vitals: Temp 98.5 ºF, BP 91/58, HR 120, RR 12 regular but shallow.
For each of the body systems listed below, type an “X” to specify whether each intervention is accepted or not accepted. Each Body system may have more than one potential intervention.
- Respiratory: Rate still with in normal limits, but breathing is shallow. You might want to monitor breathing and oxygen saturation. You need a chest x-ray now and not in the morning. Always cross out anything that delays treatment. Inebriated (drunk) clients often aspirate. A chest x-ray will help to rule out aspiration. The client fell and his neck and back are hurting. You need to maintain C-Spine to prevent the neck from flexion, extension, lateral rotation and lateral flexion. No hyperextension!
- Neurological: Neurological checks are indicated, but a lumbar puncture is not indicated. Nothing indicates that the client has meningitis.
- Cardiovascular: Blood pressure is low due to the diuretic effects of alcohol. Give fluids. The IV that is given to alcoholic clients is called banana bag (the solution has a yellow color). It contains thiamine, folic acid, and magnesium. Dopamine is not indicated. The client’s hypotension is due to dehydration.