A nurse is caring for a client who has a C4 spinal cord injury. Which of the following should the nurse recognize the client as being at the greatest risk for?
Respiratory compromise.
Stress ulcer.
Paralytic ileus.
Spinal shock.
The Correct Answer is A
Choice A reason: Respiratory compromise is the greatest risk for a client with a C4 spinal cord injury. The C4 spinal level is critical for the function of the diaphragm, which is the main muscle responsible for breathing. Injury at this level can impair diaphragmatic function, leading to difficulty in breathing or even respiratory failure. Immediate and continuous monitoring of respiratory status is essential for these patients to ensure adequate ventilation and oxygenation.
Choice B reason: Stress ulcers can develop in patients with spinal cord injuries due to the stress response and immobility. However, they are not the highest immediate risk compared to respiratory compromise, which can be life-threatening if not promptly addressed.
Choice C reason: Paralytic ileus, a condition where the intestines stop moving, can occur in spinal cord injury patients due to disruption of the nervous system control of the gut. While it is a significant concern, it is not as immediately life-threatening as respiratory compromise.
Choice D reason: Spinal shock is a condition that can occur after a spinal cord injury, leading to temporary loss of reflexes below the level of the injury. While it is an important condition to recognize and manage, the most urgent risk for a patient with a C4 injury is respiratory compromise due to the potential impact on breathing.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","E","F"]
Explanation
Choice A reason: Fever is a common sign of acute pancreatitis and indicates an inflammatory response. Inflammation of the pancreas can trigger the release of cytokines and other inflammatory mediators, leading to an elevated body temperature. This is a common symptom observed in many cases of acute pancreatitis and suggests an ongoing inflammatory process.
Choice B reason: Gray-blue discoloration of the flank or umbilical area, also known as Grey Turner's sign and Cullen's sign respectively, indicates bleeding and severe inflammation within the pancreas. These signs are indicative of retroperitoneal hemorrhage or pancreatic necrosis, which are severe complications of acute pancreatitis. The presence of such discoloration is a significant finding that suggests a more serious form of the condition.
Choice C reason: Hypertension is not typically associated with acute pancreatitis. In fact, patients with acute pancreatitis are more likely to experience hypotension due to fluid shifts, inflammatory responses, and potential hemorrhage. Monitoring blood pressure is important in these patients to manage any potential complications.
Choice D reason: Decreased amylase level is not an expected finding in acute pancreatitis. Typically, acute pancreatitis is associated with elevated levels of pancreatic enzymes such as amylase and lipase due to inflammation and damage to the pancreatic cells, which release these enzymes into the bloodstream.
Choice E reason: Nausea and vomiting are common symptoms in acute pancreatitis. The inflammation of the pancreas and the associated pain can stimulate the vomiting center in the brain and lead to nausea and vomiting. These symptoms are often severe and can significantly affect the patient's comfort and hydration status.
Choice F reason: Severe abdominal pain is one of the hallmark signs of acute pancreatitis. The pain is typically located in the upper abdomen and may radiate to the back. It is often described as constant and severe, and can be exacerbated by eating or lying flat. Effective pain management is a critical aspect of caring for patients with acute pancreatitis.
Correct Answer is C
Explanation
Choice A reason: Aspirin does have analgesic properties, which help relieve pain. However, this is not the primary reason for its administration in the context of angina-like chest pain. The analgesic effect of aspirin without sedation is more relevant in the management of general pain or headaches.
Choice B reason: Vasoconstriction and improved blood flow are not effects of aspirin. In fact, aspirin's mechanism of action involves preventing platelet aggregation, which can indirectly improve blood flow by reducing the risk of clot formation. Vasoconstriction is not an effect associated with aspirin.
Choice C reason: The primary rationale for administering aspirin to a client with angina-like chest pain is its antiplatelet effect. Aspirin inhibits platelet aggregation, reducing the risk of clot formation. This is crucial in preventing further blockage of coronary arteries, which can exacerbate angina or lead to myocardial infarction.
Choice D reason: Cardiotonic properties and improved contraction are not associated with aspirin. Cardiotonic drugs enhance the strength of the heart's contractions, which is not an action of aspirin. Aspirin's role in this context is to prevent platelet aggregation and reduce the risk of clot-related complications.
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