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 B

Explanation

A. Quadriplegia, or tetraplegia, is typically associated with injuries at or above the C4 level, not T2-T3.
B. A T2-T3 spinal cord injury can lead to loss of sensation and motor function below the level of injury, affecting the thoracic region and lower body.
C. Hemiplegia, which refers to paralysis on one side of the body, is typically due to brain injuries or strokes, not spinal cord injuries.
D. While bladder control may be affected, the most direct impact of T2-T3 injury is the loss of sensation and motor function below that level.

A. Monitor serum electrolytes B. Monitor for signs of shock. C. Monitor daily weights D. Monitor Intake and output

Correct Answer is B

Explanation

A. While monitoring serum electrolytes is important, it is secondary to assessing for immediate life-threatening conditions.
B. Monitoring for signs of shock is the priority, as Addisonian crisis can lead to severe hypotension and shock, which requires immediate intervention.
C. Monitoring daily weights can help assess fluid status but is not critical in the context of an impending crisis.
D. Monitoring intake and output is important for overall assessment but does not directly address the immediate risks associated with Addisonian crisis.

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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

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Correct Answer is B

Explanation

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Correct Answer is B

Explanation

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