A client is admitted to the intensive care unit (ICU) with a spinal cord injury (SCI) following a motor vehicle collision.
Which nurse should be contacted to coordinate the progression of the client's care?

Neurology unit supervisor.

Adult nurse practitioner.

Nurse case manager.

Risk management nurse.

Answer and Explanation

The Correct Answer is C

Choice A rationale:

The neurology unit supervisor is not the most appropriate nurse to coordinate the progression of care for a client with a spinal cord injury (SCI). While they may have expertise in neurology, the nurse case manager is specifically trained to coordinate and manage the care of patients with complex conditions, including SCI. They can facilitate communication between various healthcare providers and ensure that the client receives comprehensive care throughout their stay.

Choice B rationale:

An adult nurse practitioner may have specialized knowledge in the care of adults, but they may not have the specific skills and training required to coordinate the care of a client with a spinal cord injury in the ICU. Nurse case managers are better equipped to manage complex cases and ensure the continuity of care for the client.

Choice D rationale:

A risk management nurse focuses on minimizing healthcare-related risks and ensuring the safety of patients and staff. While their role is essential, it is not the primary responsibility to coordinate the progression of care for a client with a spinal cord injury. The nurse case manager is better suited for this role as they specialize in care coordination.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is C

Explanation

This is the priority action by the practical nurse (PN) because it can help identify and prevent a potential adverse reaction to the medication. A client who is reaching saturation with medication means that the client has reached the maximum level of medication in the blood that can produce the desired therapeutic eﬀect. However, this also means that the client is at a higher risk of developing toxicity or side eﬀects from the medication. The PN should report the findings of muscle soreness, fatigue, and warm skin to the charge nurse, as these may indicate signs of inﬂammation, infection, or allergic reaction to the medication. The PN should also monitor the client's vital signs, oxygen saturation, and laboratory values, and document the findings. The charge nurse should notify the health care provider and adjust the medication dosage or regimen as ordered.

a) Administer a PRN dose of acetaminophen.

This is not the priority action by the PN because it does not address the underlying cause of the client's symptoms. Acetaminophen is an analgesic and antipyretic medication that can help reduce pain and fever. However, it does not treat inﬂammation, infection, or allergy, which may be the reasons for the client's muscle soreness, fatigue, and warm skin. The PN should administer a PRN dose of acetaminophen only after reporting the findings to the charge nurse and obtaining an order from the health care provider.

b) Encourage the client to drink ﬂuids.

This is not the priority action by the PN because it does not address the underlying cause of the client's symptoms. Drinking ﬂuids can help maintain hydration and electrolyte balance in the body, which are important for normal functioning of cells and organs. However, it does not treat inﬂammation, infection, or allergy, which may be the reasons for the client's muscle soreness, fatigue, and warm skin. The PN should encourage the client to drink ﬂuids only after reporting the findings to the charge nurse and obtaining an order from the health care provider.

d) Monitor the client's serum lipid levels.

This is not the priority action by the PN because it is not related to the client's symptoms. Serum lipid levels are measures of fats and cholesterol in the blood, which are important for energy production, hormone synthesis, and cell membrane structure. However, they are not related to inﬂammation, infection, or allergy, which may be the reasons for the client's muscle soreness, fatigue, and warm skin. The PN should monitor the client's serum lipid levels only if they are prescribed a medication that can aﬀect lipid metabolism, such as statins or fibrates.

A. Palpate for pedal edema. B. Assess blood pressure. C. Measure body temperature. D. Observe breathing patterns.

Correct Answer is D,B,C,A

Explanation

Rationalizing the Priority
1. Airway/Breathing (D):
The "A" and "B" of the ABCs take precedence. In myxedema coma, hypoventilation is a primary concern. The client may experience respiratory muscle weakness or a decreased drive to breathe, leading to CO₂ retention and respiratory failure. Assessing the rate, depth, and effort of breathing is the absolute first step.

2. Circulation (B):
Once the airway is confirmed, you assess the "C" (Circulation). Myxedema coma causes severe bradycardia and decreased cardiac output, which leads to hypotension. Assessing blood pressure tells the nurse if the client is in cardiogenic shock.

3. Vital Signs/Metabolic State (C):
Hypothermia is a hallmark sign of myxedema coma (temperatures can often drop below 95°F or 35°C). While critical, it is addressed after ensuring the heart is pumping and the lungs are moving air. Monitoring temperature is vital because rapid rewarming can actually cause vasodilation and worsen shock.

4. Focused Physical Assessment (A):
Palpating for edema is an important part of a head-to-toe assessment for hypothyroidism (non-pitting mucinous edema is common), but it is not a life-saving intervention. It is a secondary assessment compared to the vital signs and respiratory status.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A client is admitted to the intensive care unit (ICU) with a spinal cord injury (SCI) following a motor vehicle collision. Which nurse should be contacted to coordinate the progression of the client's care?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client who is reaching saturation with medication reports the onset of muscle soreness and fatigue, and the practical nurse (PN) notes that the client's skin is warm to the touch. Which action by the PN is a priority?

Correct Answer is C

Explanation

A client who is admitted for primary hypothyroidism has early signs of myxedema coma. In assessing the client, in which sequence should the nurse complete these actions? (Rank the first action at the top with the remainder in descending order.).

Correct Answer is D,B,C,A

Explanation

When developing a teaching plan for a client with newly diagnosed type 1 diabetes, the nurse should explain that an increased thirst is an early sign of diabetic ketoacidosis (DKA). Which action should the nurse instruct the client to implement if this sign of DKA occurs?

A nurse is documenting the data collected from an ongoing assessment of a client who has diabetes mellitus. The nurse writes, “The client reports feeling thirsty and hungry all the time.” How should the nurse label this type of data?

A client with delusions tells the nurse, "You aren't doing your job. Go get those people over there and shoot them before they get me." Which statement is the nurse's best response?

The nurse is caring for a client who has been admitted with recurring migraine headaches. To assess the quality of the client's pain experienced from the migraine headache, which approach should the nurse use?

The practical nurse (PN) learns that a client who is receiving chemotherapy has developed stomatitis. Which information should the PN obtain from the client during a focused assessment?

A nurse is teaching a newly licensed nurse about contributing factors that can lead to the development of conduct disorder. Which of the following factors related to family dynamics should the nurse include in the teaching?

The nurse completes percussion of the abdomen on an older adult client. Which finding is considered normal for this client?

A client is admitted to the intensive care unit (ICU) with a spinal cord injury (SCI) following a motor vehicle collision.
Which nurse should be contacted to coordinate the progression of the client's care?