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.

Answer and Explanation

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.

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Correct Answer is ["D"]

Explanation

Choice A reason: Administering a vasopressor is not appropriate for low afterload. Vasopressors are used to increase blood pressure by causing vasoconstriction, which increases afterload. However, the administration of a vasopressor for low afterload is contradictory because the goal for low afterload would be to reduce the strain on the heart, not to increase it.

Choice B reason: Administering a vasodilator for low afterload is not correct. Vasodilators decrease afterload by causing the blood vessels to widen, reducing the resistance the heart has to pump against. Administering a vasodilator to treat low afterload is inappropriate because it would further lower afterload, potentially leading to inadequate perfusion and worsening cardiac output.

Choice C reason: Administering diuretics for low right atrial (RA) pressure is inappropriate. Diuretics help to remove excess fluid from the body, reducing blood volume and venous pressure. However, if a patient has low right atrial pressure, reducing blood volume further with diuretics could exacerbate the issue, leading to decreased cardiac output and poor perfusion.

Choice D reason: Administering a fluid bolus is the correct intervention for low preload. Preload refers to the volume of blood in the ventricles at the end of diastole. If preload is low, administering fluids increases blood volume, which enhances ventricular filling and improves cardiac output. This intervention helps to stabilize hemodynamics and improve overall perfusion.

Choice E reason: Administering a diuretic or vasodilator is the appropriate intervention for high preload. High preload indicates an excess of blood volume returning to the heart, which can strain the cardiac muscle and reduce efficiency. Diuretics help remove excess fluid, while vasodilators decrease venous return and reduce the volume of blood the heart has to handle, thus optimizing cardiac function and output.

A. Provide at least 5000 kcal/day. B. Start an oral diet on the first day. C. Administer a diet high in protein. D. Collaborate with a registered dietitian. E. Offer frequent high-calorie snacks.

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

Explanation

Choice A reason: Providing at least 5000 kcal/day is essential for a patient with burn injuries. Burns significantly increase the body's metabolic rate and caloric needs to support the healing process and prevent catabolism. Ensuring an adequate caloric intake helps meet the energy demands required for tissue repair and recovery.

Choice B reason: Starting an oral diet on the first day may not be appropriate for all burn patients, particularly those with extensive burns or those who are not yet stable. Nutrition needs should be carefully assessed, and feeding may begin via alternative methods such as enteral nutrition until the patient is ready for oral intake.

Choice C reason: Administering a diet high in protein is crucial for burn patients, as protein is essential for wound healing, maintaining lean body mass, and supporting the immune system. Protein intake should be increased to help repair damaged tissues and promote recovery.

Choice D reason: Collaborating with a registered dietitian is important to create an individualized nutrition plan that meets the specific needs of the burn patient. A dietitian can provide expertise in calculating caloric and protein requirements, recommending appropriate supplements, and monitoring the patient's nutritional status.

Choice E reason: Offering frequent high-calorie snacks helps ensure that the patient meets their increased caloric needs. Small, frequent meals and snacks can be more manageable for patients with reduced appetite or those who have difficulty consuming large meals. High-calorie snacks provide additional energy to support healing and recovery.

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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?

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Naxlex Comprehensive Predictor Exams

Correct Answer is ["D"]

Explanation

A nurse plans care for a patient with burn injuries. Which interventions would the nurse include in this patient's plan of care to ensure adequate nutrition? Select all that apply.

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

Explanation

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