A nurse is assessing a client who has sustained a C4 spinal cord injury. Which assessment finding would indicate a potential need for ventilatory support?

The client is experiencing decreased sensation in the upper extremities.

The client shows signs of respiratory distress and inability to control coughing.

The client demonstrates normal full range of motion in their extremities.

The client reports normal swallowing and does not exhibit any dysphagia.

Answer and Explanation

The Correct Answer is B

A spinal cord injury at the C4 level can significantly impair respiratory function because it affects the phrenic nerve, which originates from C3–C5 and controls the diaphragm. Damage at or above this level can reduce or eliminate effective diaphragmatic breathing, making ventilatory support potentially necessary. Clients may initially have some spontaneous breathing but are at high risk for rapid respiratory compromise due to weak cough effort and reduced airway clearance. Continuous respiratory assessment is essential to detect early signs of failure.

Rationale:
A. Decreased sensation in the upper extremities is an expected finding in cervical spinal cord injuries but does not directly indicate respiratory compromise. Sensory deficits reflect neurological involvement but do not determine ventilatory function. The priority concern in C4 injuries is respiratory muscle impairment rather than sensory changes.

B. Signs of respiratory distress and inability to control coughing indicate compromised airway protection and reduced ventilatory capacity. Weak or absent cough reflex increases the risk of secretion retention and airway obstruction. In a C4 injury, impaired diaphragmatic and accessory muscle function can rapidly lead to respiratory failure, making ventilatory support necessary.

C. Normal full range of motion in the extremities would be unexpected in a C4 spinal cord injury, which typically results in significant motor deficits. However, this finding does not provide information about respiratory status. The primary concern in this context remains breathing adequacy rather than limb movement.

D. Normal swallowing and absence of dysphagia are positive findings but do not rule out respiratory compromise in a C4 injury. While swallowing function may remain intact depending on the extent of injury, respiratory muscle impairment can still progress. Ventilatory support decisions are based on breathing effectiveness rather than swallowing ability alone.

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Correct Answer is B

Explanation

Circumferential burns occur when full-thickness or deep partial-thickness injury forms a rigid, inelastic eschar around a limb. As edema develops beneath the tight burned tissue, circulation can become severely compromised, leading to increased compartment pressure and potential ischemia. In pediatric clients, the risk of rapid progression to compartment syndrome is high due to smaller limb diameter and faster edema formation. Management focuses on restoring perfusion and preventing tissue necrosis.

Rationale:
A. Application of a topical antimicrobial to the burned area is important for infection prevention but is not the priority in this scenario. While it helps reduce bacterial colonization on burn surfaces, it does not address the immediate risk of vascular compromise caused by restricted circulation. Infection control becomes relevant after circulation is stabilized.

B. Immediate escharotomy is the priority intervention because circumferential burns can act like a tourniquet, restricting blood flow as edema increases. Escharotomy involves surgical incision through the eschar to relieve pressure and restore distal perfusion. This intervention prevents ischemia, compartment syndrome, and potential limb loss, making it the most urgent action.

C. Fluid resuscitation via large-bore intravenous access is essential in burn management but does not directly relieve localized vascular compression in a circumferential burn. Although fluid therapy helps maintain systemic perfusion and prevent hypovolemic shock, it does not address mechanical restriction of blood flow to the limb.

D. Administering pain medication is necessary for comfort but is not the priority intervention in the presence of threatened limb perfusion. Pain management does not resolve impaired circulation or prevent ischemic injury. It is provided after ensuring adequate blood flow and tissue viability have been addressed.

A. Fever and fluid retention B. A steady increase in urine output C. Decreased blood creatinine levels D. Increased appetite and weight gain

Correct Answer is A

Explanation

After a kidney transplant, the immune system may recognize the transplanted organ as foreign and initiate an inflammatory response known as acute rejection. This typically occurs within days to months post-transplant and can compromise graft function if not identified early. Clinical monitoring focuses on early signs of inflammation, reduced renal function, and systemic changes indicating immune activation. Prompt recognition is essential to preserve graft viability and prevent irreversible damage.

Rationale:
A. Fever and fluid retention are key indicators of potential acute rejection. Fever reflects an inflammatory or immune response against the transplanted kidney. Fluid retention occurs due to impaired renal function as the rejecting kidney loses its ability to regulate fluid balance effectively, often leading to edema and hypertension.

B. A steady increase in urine output is not typically associated with acute rejection and may instead indicate improving graft function or appropriate response to therapy. In acute rejection, urine output more commonly decreases due to declining renal function and reduced glomerular filtration.

C. Decreased blood creatinine levels suggest improved kidney function rather than rejection. In acute rejection, serum creatinine typically rises due to impaired filtration and declining graft performance. A downward trend in creatinine is a reassuring finding, not a warning sign.

D. Increased appetite and weight gain are not specific indicators of acute transplant rejection. While weight gain may occur due to fluid retention, increased appetite alone is not associated with immune-mediated graft dysfunction. More specific signs such as fever, rising creatinine, and reduced urine output are more clinically relevant.

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A nurse is assessing a client who has sustained a C4 spinal cord injury. Which assessment finding would indicate a potential need for ventilatory support?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is A

Explanation

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