A patient is admitted to the emergency department with a possible cervical spinal cord injury following an automobile crash. During admission of the patient, what is the highest priority for the nurse?
Maintaining a patent airway
Maintaining immobilization of the cervical spine
Assessing the patient for head and other injuries
Assessing the patient’s motor and sensory function
The Correct Answer is A
The highest priority for a patient with a possible cervical spinal cord injury is maintaining a patent airway. High cervical injuries can impair respiratory muscles, putting the patient at risk for respiratory compromise or arrest. Securing airway patency takes precedence over other assessments and interventions to prevent hypoxia and further neurologic injury.
Rationale for correct answer:
1. Maintaining a patent airway. Cervical SCI, especially above C4, can compromise the diaphragm and intercostal muscles. Ensuring adequate oxygenation is life-saving and prevents secondary injury caused by hypoxia. Airway management takes precedence even if spinal immobilization is required simultaneously.
Rationale for incorrect answers:
2. Maintaining immobilization of the cervical spine. While critical to prevent further cord injury, airway compromise has a more immediate threat to life and must be addressed first.
3. Assessing the patient for head and other injuries. A full trauma assessment is important but secondary to ensuring airway and oxygenation.
4. Assessing the patient’s motor and sensory function. Neurologic assessment is essential for baseline documentation, but interventions must prioritize life-threatening problems like airway compromise.
Take-home points:
- Airway management is the top priority in cervical spinal cord injuries.
- Immobilization should then be maintained to prevent further injury.
- Neurologic and trauma assessments follow stabilization of life-threatening conditions.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The highest priority in a patient with a recent T12 spinal cord injury is prevention of further spinal cord damage. At one week post-injury, the spinal cord remains vulnerable to secondary injury from movement, improper handling, or additional trauma. Protecting the spinal cord ensures that existing neurological function is preserved, which is critical for long-term outcomes.
Rationale for correct answer:
1. Prevention of further damage to the spinal cord. Maintaining spinal immobilization, careful positioning, and avoiding movements that could exacerbate injury are essential to prevent additional neurological loss. Preserving remaining function is the most critical immediate concern.
Rationale for incorrect answers:
2. Prevention of contractures of the lower extremities. This is important for long-term mobility and function but is a secondary priority compared to protecting the spinal cord.
3. Prevention of skin breakdown of areas that lack sensation. Pressure injury prevention is critical, but it is not more urgent than preventing permanent neurological damage.
4. Prevention of postural hypotension when placing the client in a wheelchair. Orthostatic hypotension precautions are necessary during rehabilitation but are not the immediate priority in the acute post-injury phase.
Take-home points:
- Immediate care after SCI focuses on protecting the spinal cord to preserve neurological function.
- Secondary concerns include contracture prevention, skin care, and hemodynamic stability.
- Early and careful handling can significantly influence long-term functional outcomes.
Correct Answer is C
Explanation
In a patient with a spinal cord injury at or above T6, sudden severe headache and nausea are hallmark signs of autonomic dysreflexia, a life-threatening emergency caused by an exaggerated sympathetic response to noxious stimuli (such as bladder distention, fecal impaction, or skin irritation). The nurse’s first action is to check the patient’s blood pressure to confirm the diagnosis, since autonomic dysreflexia results in severe hypertension.
Rationale for correct answer:
3. Take the patient’s blood pressure. Confirms whether the symptoms are due to autonomic dysreflexia by detecting dangerous hypertension, which requires immediate intervention.
Rationale for incorrect answers:
1. Call the physician. Contacting the provider is important but not the first action—the nurse must first assess the patient’s BP to confirm the condition.
2. Check the patient’s temperature. Headache and nausea are not early signs of infection in this context; checking temperature delays recognition of a true emergency.
4. Elevate the head of the bed to 90 degrees. This is an essential intervention to lower blood pressure, but assessment (BP check) must be done first to confirm the cause of symptoms.
Take-home points:
- Autonomic dysreflexia presents with severe headache, nausea, flushing, bradycardia, and hypertension in SCI patients at or above T6.
- First priority is to check blood pressure to confirm the condition.
- Once confirmed, the nurse elevates the HOB, removes noxious stimuli, and notifies the physician.
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