A nurse is in the emergency department (ED) and is caring for a client that has arrived by ambulance after a cervical spinal cord injury. Which assessment should be the priority for the nurse to perform at this time?

Assess the client's respiratory status and airway patency.

Assess the client's extremity strength and sensation.

Assess the client's pain level and provide pain management.

Assess the client's level of consciousness and orientation.

Answer and Explanation

The Correct Answer is A

A. Assessing respiratory status and airway patency is the highest priority in this situation due to the risk of respiratory compromise from cervical spinal cord injuries, which can affect the diaphragm and other respiratory muscles.
B. While assessing extremity strength and sensation is important, it comes after ensuring the client’s airway and breathing are stable.
C. Pain management is essential, but addressing immediate life-threatening conditions takes precedence over pain assessment.
D. Assessing the client's level of consciousness is crucial for overall evaluation but does not take priority over ensuring adequate respiratory function in the context of a cervical spinal cord injury.

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Correct Answer is A

Explanation

A. Mastoiditis often results in inflammation and infection that extend to the middle ear, causing the tympanic membrane to appear red, dull, thickened, and immobile upon examination.
B. A transparent and clear tympanic membrane is typical in a healthy ear, not in cases of mastoiditis.
C. A pearly colored tympanic membrane is also indicative of a normal, healthy ear without infection.
D. A pink-colored tympanic membrane may suggest mild irritation but is not a characteristic finding of mastoiditis.

A. Administer calcium binders B. Administer vitamin D supplements C. Administer fluids up to 3000 ml/day D. Administer Furosemide (Lasix) per orders E. Administer oral phosphates

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

Explanation

A. Calcium binders are used to help decrease the amount of calcium absorbed from the gastrointestinal tract, thus lowering calcium levels in the blood.
B. Vitamin D supplements would actually increase calcium levels by enhancing intestinal absorption, so this option is not appropriate in hypercalcemia.
C. Administering fluids helps to dilute serum calcium levels and promote renal excretion of calcium, making it a priority treatment.
D. Furosemide (Lasix) can help promote diuresis, thereby increasing the excretion of calcium through the urine, which is beneficial in managing hypercalcemia.
E. Oral phosphates may be used in some cases to manage hypercalcemia, but they are not a first-line treatment and their administration should be carefully considered in conjunction with other treatments.

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A nurse is in the emergency department (ED) and is caring for a client that has arrived by ambulance after a cervical spinal cord injury. Which assessment should be the priority for the nurse to perform at this time?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is performing an otoscopic examination on a client with mastoiditis. On examination of the tympanic membrane, which finding should the nurse expect to observe?

Correct Answer is A

Explanation

A nurse is caring for a client with hyperparathyroidism and hypercalcemia. The nurse should expect to administer which of the following priority treatments? SELECT ALL THAT APPLY.

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

Explanation

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