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 C

Explanation

A. The supine position can increase ICP and is not recommended for clients with elevated ICP.
B. Instructing the client to pull themselves up may increase ICP due to straining.
C. Log rolling helps maintain spinal alignment and minimizes abrupt head movement, which is essential in managing ICP.
D. Sitting with legs dangling may cause a sudden shift in intracranial pressure and is not advised for these clients.

A. "The pool water has chlorine that is killing all of the good bacteria." B. "The pool water is entering your Eustachian tubes." C. "The pool water has microorganisms that are entering your ears." D. "The pool water is drying out your ears, causing skin breakdown."

Correct Answer is C

Explanation

A. While chlorine can kill some bacteria, it does not prevent all microbial growth and does not directly explain ear infections.
B. Pool water entering the Eustachian tubes is unlikely; infections are more commonly related to pathogens in the water.
C. The best response addresses the presence of microorganisms in pool water that can enter the ear and potentially lead to infections, such as swimmer's ear (otitis externa).
D. Pool water is not typically associated with drying out the ears; rather, it can lead to excess moisture, which can promote bacterial growth.

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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

A nurse is caring for a client who has increased intracranial pressure (ICP) following a closed-head injury. Which of the following positioning techniques should the nurse implement?

Correct Answer is C

Explanation

A client who swims several times a week asks the nurse, "Why are ears prone to frequent infection?" What is the nurse's best response?

Correct Answer is C

Explanation

The nurse is providing teaching on the miotic medication the client has been prescribed for glaucoma. The client asks the nurse about the purpose of the medication. Which response should the nurse provide to the client?

A nurse is assessing a client with autonomic dysreflexia. The nurse correlates which clinical manifestations to autonomic dysreflexia in a client with a spinal cord injury?

A nurse is caring for a client who has had a spinal cord injury at the level of the T2-T3 vertebrae. When planning care, the nurse should anticipate which of the following types of disability?

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?

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A nurse is caring for a client newly diagnosed with hyperthyroidism. The nurse recognizes that which of the following is a potential severe complication of hyperthyroidism?