A patient is admitted to the emergency department with a spinal cord injury at the level of T2 following a traumatic fall from a roof. Which finding is of most concern to the nurse?

Heart rate of 45 beats/min

SpO2 of 91%

Blood pressure of 98/62 mmHg

Loss of motor and sensory function in extremities

Answer and Explanation

The Correct Answer is A

Choice A reason:

A heart rate of 45 beats/min (bradycardia) is concerning because it indicates a significant impact on the autonomic nervous system, which can occur with high thoracic spinal cord injuries. Bradycardia can lead to inadequate cardiac output and may require immediate intervention to prevent further cardiovascular compromise.

Choice B reason:

An SpO2 of 91% is slightly below normal but not immediately life-threatening. While monitoring and addressing oxygen saturation is important, it is not as critical as the hemodynamic instability indicated by bradycardia in this context.

Choice C reason:

A blood pressure of 98/62 mmHg is on the lower end of the normal range but not immediately alarming. While hypotension is a concern in spinal cord injury patients, the more pressing issue in this scenario is the bradycardia, which can have more immediate and severe consequences.

Choice D reason:

Loss of motor and sensory function in the extremities is a significant finding in spinal cord injuries and indicates the level and severity of the injury. However, it is not immediately life-threatening and does not require as urgent intervention as bradycardia in this acute setting.

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Correct Answer is D

Explanation

Choice A reason:

Monitoring sodium levels is important when administering mannitol, but it is not the primary indicator of the drug's effectiveness. Mannitol is an osmotic diuretic used to reduce intracranial pressure, and its effectiveness is better assessed by other means.

Choice B reason:

Fluid intake is important to monitor to ensure proper hydration status, but it does not directly indicate the effectiveness of mannitol. The primary focus should be on the patient's output to assess the diuretic effect.

Choice C reason:

Heart rate monitoring is essential for overall patient care but does not directly indicate the effectiveness of mannitol. Changes in heart rate can occur due to various factors and are not specific to mannitol's action.

Choice D reason:

Urine output is the most direct measure of mannitol's effectiveness. As an osmotic diuretic, mannitol promotes diuresis, and increased urine output indicates that the drug is effectively reducing intracranial pressure.

A. Administer fluids. B. Give pain medications as ordered. C. Prepare the patient for a CT scan. D. Prepare to assist with intubation.

Correct Answer is D

Explanation

Choice A reason:

Administering fluids is important for maintaining hemodynamic stability, but it is not the immediate priority for a patient with compromised respiration and low oxygen saturation.

Choice B reason:

Giving pain medications is necessary for patient comfort but is not the priority in a situation where the patient's respiratory status is severely compromised.

Choice C reason:

Preparing the patient for a CT scan can help assess internal injuries but is not the immediate priority when the patient is cyanotic and has low oxygen saturation. Immediate respiratory support is required first.

Choice D reason:

Preparing to assist with intubation is the priority action. The patient's oxygen saturation is critically low, and the chest wall is not moving normally, indicating potential respiratory failure. Intubation and mechanical ventilation are necessary to secure the airway and provide adequate oxygenation.

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A patient is admitted to the emergency department with a spinal cord injury at the level of T2 following a traumatic fall from a roof. Which finding is of most concern to the nurse?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

To evaluate the effectiveness of mannitol, the nurse should monitor:

Correct Answer is D

Explanation

A patient is brought to the emergency department after sustaining injuries in a severe car crash. The patient's chest wall does not appear to be moving normally with respirations, oxygen saturation is 82%, and the patient is cyanotic. What action by the nurse is the priority?

Correct Answer is D

Explanation

As a community health nurse, you are planning to conduct an education session on prevention strategies for spinal cord injuries. Which population would benefit most from this education?

The nurse is caring for a mechanically ventilated spinal cord injury patient in the ICU. To avoid the complication of autonomic dysreflexia, the nurse plans to implement the following orders:

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