A nurse is caring for a client who was brought to the emergency department (ED) by EMS after diving into a lake and losing consciousness. The client was intubated in the field by the paramedics. A CT of the head and neck revealed a spinal cord injury at the level of C3-4. What is the priority nursing action?
Maintain the cervical collar in place.
Ask the client if they remember any events around the time of the injury.
Explain to the client that they will never be able to walk again.
Notify the client's parents that they are in the ED.
The Correct Answer is A
Choice A Reason:
Maintaining the cervical collar in place is crucial for a client with a spinal cord injury at the level of C3-4. This action prevents further damage to the spinal cord by immobilizing the neck and maintaining proper alignment. Any movement could exacerbate the injury, potentially leading to more severe neurological deficits or even paralysis.
Choice B Reason:
Asking the client if they remember any events around the time of the injury is not the priority in this situation. While obtaining a history is important, it should not take precedence over stabilizing the spinal cord to prevent further injury. The primary focus should be on ensuring the client's safety and preventing additional harm.
Choice C Reason:
Explaining to the client that they will never be able to walk again is inappropriate and premature. The prognosis for spinal cord injuries can vary widely, and it is essential to provide accurate information based on a thorough assessment and consultation with specialists. Additionally, delivering such news requires sensitivity and should be done in a supportive manner.
Choice D Reason:
Notifying the client's parents that they are in the ED is important for family communication and support. However, it is not the immediate priority. The primary focus should be on stabilizing the client's condition and preventing further injury. Once the client is stabilized, the nurse can then inform the family.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","D","E","F"]
Explanation
Choice A Reason:
Neurogenic shock occurs due to a disruption in the autonomic nervous system, often resulting from spinal cord injuries. This disruption leads to a loss of sympathetic tone, causing widespread vasodilation and a subsequent drop in blood pressure. The hallmark of neurogenic shock is hypotension with bradycardia, which differentiates it from other types of shock that typically present with tachycardia. The loss of vascular tone results in pooling of blood in the extremities, reducing venous return to the heart and decreasing cardiac output.
Choice B Reason:
Hypovolemic shock is caused by a significant loss of blood or fluids, leading to inadequate circulating volume. This can result from trauma, surgery, gastrointestinal bleeding, or severe dehydration. The primary mechanism is a reduction in preload, which decreases stroke volume and cardiac output. Clinical signs include tachycardia, hypotension, and cool, clammy skin. Rapid fluid resuscitation is critical to restore circulating volume and improve tissue perfusion.
Choice C Reason:
Metabolic shock is not a recognized type of shock in medical literature. The term might be confused with metabolic acidosis, which can occur secondary to shock but is not a primary cause. Metabolic acidosis results from the accumulation of lactic acid due to anaerobic metabolism when tissues are inadequately perfused. Therefore, metabolic shock is not considered a valid type of shock.
Choice D Reason:
Anaphylactic shock is a severe, life-threatening allergic reaction that leads to widespread vasodilation, increased capillary permeability, and bronchoconstriction. Common triggers include foods, insect stings, medications, and latex. Symptoms include hypotension, swelling, difficulty breathing, and hives. Immediate administration of epinephrine is crucial to counteract the severe allergic response and stabilize the patient.
Choice E Reason:
Septic shock results from a severe infection that leads to systemic inflammation and widespread vasodilation. The infection triggers an overwhelming immune response, causing damage to blood vessels and organs. Clinical features include fever, hypotension, tachycardia, and altered mental status. Early recognition and aggressive treatment with antibiotics and fluid resuscitation are essential to improve outcomes.
Choice F Reason:
Cardiogenic shock occurs when the heart fails to pump effectively, leading to inadequate tissue perfusion. Common causes include myocardial infarction, severe heart failure, and arrhythmias. Symptoms include hypotension, tachycardia, and signs of poor perfusion such as cool extremities and altered mental status. Treatment focuses on improving cardiac output through medications, mechanical support, or revascularization procedures.
Correct Answer is D
Explanation
Choice A Reason:
Consuming a diet high in vitamin K to promote clotting is not typically recommended for patients with DIC. While vitamin K is essential for clotting, DIC involves both excessive clotting and bleeding. Increasing vitamin K intake could exacerbate clotting issues without addressing the underlying imbalance.
Choice B Reason:
Stopping all medications to prevent interactions with clotting factors is not advisable. Patients with DIC often require medications to manage their condition, including anticoagulants and treatments for the underlying cause. Discontinuing all medications could lead to uncontrolled symptoms and complications.
Choice C Reason:
Engaging in physical activity to promote blood flow is generally beneficial for overall health, but in the context of DIC, it must be approached with caution. Physical activity can increase the risk of injury and bleeding, which is a significant concern for patients with DIC. Therefore, any exercise regimen should be carefully monitored and tailored to the patient's condition.
Choice D Reason:
Avoiding activities that may cause injury or bleeding is crucial for patients with DIC. Due to the risk of spontaneous bleeding and the potential for minor injuries to lead to significant blood loss, patients must take precautions to minimize these risks. This includes avoiding contact sports, using soft-bristled toothbrushes, and being cautious with sharp objects.
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