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 C

Explanation

Choice A reason:

The application of PEEP does not inherently increase the need for FiO2 (fraction of inspired oxygen) administration. PEEP helps improve oxygenation, potentially reducing the need for higher FiO2 levels.

Choice B reason:

While PEEP can contribute to better lung inflation by keeping the alveoli open, this is a secondary effect. The primary goal of PEEP is to prevent alveolar collapse at the end of expiration.

Choice C reason:

PEEP prevents alveolar collapse during expiration, which is its primary therapeutic effect. By maintaining a certain level of pressure in the lungs at the end of expiration, PEEP ensures that the alveoli remain open, improving gas exchange and oxygenation.

Choice D reason:

Although PEEP can help reduce the risk of atelectasis (collapse of part or all of a lung), it does not directly prevent barotrauma. Barotrauma is related to high airway pressures, and careful monitoring of ventilator settings is necessary to avoid it.

A. Elevate the head of the bed immediately and notify the provider B. Administer PRN tylenol for the patient's headache C. Recheck all of the patient's vital signs D. Elevate the patient's knees and lower the head of the bed

Correct Answer is A

Explanation

Choice A reason:

Elevating the head of the bed and notifying the provider is the correct initial action when a patient with a spinal cord lesion at T4 experiences a significantly elevated blood pressure (190/100), headache, and flushing. These symptoms suggest autonomic dysreflexia, a potentially life-threatening condition that requires immediate intervention. Elevating the head of the bed helps to lower blood pressure, and notifying the provider ensures that further medical treatment can be administered promptly.

Choice B reason:

Administering PRN Tylenol for the patient's headache is not the appropriate first action in this scenario. While Tylenol may help with the headache, it does not address the underlying cause of the elevated blood pressure and autonomic dysreflexia. Immediate intervention to lower blood pressure is critical to prevent complications.

Choice C reason:

Rechecking all of the patient's vital signs is important but not the priority action in this situation. The nurse should first take measures to lower the blood pressure and address the symptoms of autonomic dysreflexia by elevating the head of the bed and notifying the provider. Monitoring vital signs can be done concurrently, but it should not delay the immediate intervention required.

Choice D reason:

Elevating the patient's knees and lowering the head of the bed is contraindicated in this situation. Lowering the head of the bed can further increase intracranial pressure and exacerbate symptoms of autonomic dysreflexia. The proper position to help reduce blood pressure is to elevate the head of the bed.

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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

When planning care for a patient on a mechanical ventilator, the nurse understands that the application of positive end-expiratory pressure (PEEP) to the ventilator settings has which therapeutic effect?

Correct Answer is C

Explanation

A patient with a spinal cord lesion at T4 tells the nurse that he has a headache and feels flushed. The BP is significantly elevated to 190/100. The first action by the nurse is to:

Correct Answer is A

Explanation

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