A client with a spinal cord injury at the level C3 to C4 is being cared for by the nurse in the emergency department. What is the priority nursing action?

Assess the level at which the client has intact sensation

Determine the level at which the client has retained mobility

Monitor respiratory effort and oxygen saturation level

Check the blood pressure and pulse for signs of spinal shock

Answer and Explanation

The Correct Answer is C

Choice A reason:

Assessing the level at which the client has intact sensation is important in the overall management of a spinal cord injury. However, it is not the immediate priority in an emergency setting. Ensuring the client's respiratory function and oxygenation is the first concern to stabilize the patient.

Choice B reason:

Determining the level at which the client has retained mobility is part of the assessment of a spinal cord injury but is secondary to monitoring and ensuring adequate respiratory effort and oxygen saturation. Mobility can be evaluated once the patient's vital signs are stable.

Choice C reason:

Monitoring respiratory effort and oxygen saturation level is the priority nursing action for a client with a spinal cord injury at the C3 to C4 level. Injuries at this level can impair the diaphragm and other muscles essential for breathing. Ensuring that the patient has adequate respiratory function and oxygenation is critical to prevent respiratory failure.

Choice D reason:

Checking blood pressure and pulse for signs of spinal shock is important, but the immediate priority is to ensure that the patient is breathing effectively and has sufficient oxygen saturation. Respiratory compromise can occur quickly with high-level spinal cord injuries, making it the most urgent concern.

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Correct Answer is ["C","D","E"]

Explanation

Choice A reason:

Soaking the pin sites with alcohol pads is not recommended as it can dry out the skin and increase the risk of infection. Pin site care typically involves using saline or other recommended solutions to clean the area gently.

Choice B reason:

Removing the vest when bathing the patient is not recommended. The vest provides stability and support for the spinal fracture, and removing it can compromise the patient's safety. Alternative methods should be used to maintain hygiene without removing the vest.

Choice C reason:

Assessing the chest and back for skin breakdown is crucial in patients with a halo device to prevent pressure ulcers and other skin issues. Regular assessment helps identify any potential problems early.

Choice D reason:

Assessing pin sites frequently for signs of infection is essential to prevent complications. Infection at the pin sites can lead to serious issues, and frequent monitoring ensures any signs of infection are caught and treated promptly.

Choice E reason:

Taping a halo wrench to the vest is important for emergencies. The wrench is necessary to quickly remove the halo device if needed in an emergency situation, such as if the patient requires resuscitation.

A. Palpate the bladder for distention. B. Initiate oxygen via a nasal cannula. C. Place the patient in a supine position. D. Administer a prescribed beta-blocker.

Correct Answer is A

Explanation

Choice A reason:

Palpating the bladder for distention is the first action the nurse should take. The patient's symptoms suggest autonomic dysreflexia, a condition that can be triggered by bladder distention. Relieving the distention can help resolve the hypertensive crisis.

Choice B reason:

Initiating oxygen via a nasal cannula may be necessary if the patient is experiencing respiratory distress, but it is not the primary intervention for autonomic dysreflexia. The focus should be on identifying and resolving the triggering cause.

Choice C reason:

Placing the patient in a supine position is contraindicated in autonomic dysreflexia as it can worsen the condition by further increasing blood pressure. The patient should be positioned upright if tolerated.

Choice D reason:

Administering a prescribed beta-blocker may help lower blood pressure, but it is not the first action. The underlying cause of autonomic dysreflexia must be addressed to prevent recurrence.

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A client with a spinal cord injury at the level C3 to C4 is being cared for by the nurse in the emergency department. What is the priority nursing action?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is preparing to care for a patient with a spinal fracture who has a halo device in place. The nurse plans to implement the following orders:

Correct Answer is ["C","D","E"]

Explanation

A nurse assesses a patient with a spinal cord injury at level T5. The patient's blood pressure is 184/95 mm Hg, and the patient presents with a flushed face and blurred vision. What action would the nurse take first in response to this complication?

Correct Answer is A

Explanation

A patient with a spinal cord lesion at T4 tells the nurse that he has a headache and feels flushed. The BP is significantly elevated to 190/100. The first action by the nurse is to:

A nurse is caring for a patient who has a closed-head injury with ICP readings ranging from 16-22 mm Hg. What actions should the nurse take to decrease the potential for raising the client's ICP? Select all that apply.

A nurse is caring for a client in acute respiratory failure who is receiving mechanical ventilation. Which of the following assessments is the best method to determine the effectiveness of the current treatments?

When planning care for a patient on a mechanical ventilator, the nurse understands that the application of positive end-expiratory pressure (PEEP) to the ventilator settings has which therapeutic effect?

A nursing student studying spinal cord injury recognizes all of the following to be causes of secondary injuries:

The nurse is caring for a mechanically ventilated spinal cord injury patient in the ICU. To avoid the complication of autonomic dysreflexia, the nurse plans to implement the following orders:

To evaluate the effectiveness of mannitol, the nurse should monitor:

A nursing student studying spinal cord injury recognizes all of the following to be causes of secondary injuries: