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 B

Explanation

Choice A reason:

A temperature of 96.8°F is within the normal range for a human body (97.8°F to 99.1°F). However, it does not necessarily indicate the desired effect of Dopamine. Dopamine is primarily used to improve blood flow and cardiac output, particularly in critically ill patients. Therefore, temperature alone is not a reliable indicator of its effectiveness.

Choice B reason:

Blood pressure of 110/68 mmHg suggests that the Dopamine is effectively maintaining the patient's hemodynamic stability. Dopamine is often used to support blood pressure in patients with hypotension, particularly after spinal cord injuries. Maintaining an adequate blood pressure ensures that vital organs receive sufficient blood flow, which is a key therapeutic goal of Dopamine administration.

Choice C reason:

A respiratory rate of 20 breaths/min is considered normal for an adult (12-20 breaths/min). While normal respiratory rate is a positive sign, it is not a direct measure of Dopamine's effectiveness. Dopamine's primary action is on the cardiovascular system, so a normal respiratory rate alone does not necessarily indicate that the drug is having the desired effect.

Choice D reason:

A heart rate of 70 beats/min is within the normal range for adults (60-100 beats/min). Similar to the respiratory rate, while a normal heart rate is beneficial, it is not a direct indicator of Dopamine's effectiveness. Dopamine's role in improving cardiac output and blood pressure is more critical in assessing its desired effects.

A. Level of consciousness. B. Focal neurological exam. C. Body posturing. D. Vital signs.

Correct Answer is A

Explanation

Choice A reason:

Assessing the level of consciousness is the most important nursing assessment for detecting early signs of a declining condition in a patient with a severe concussion. Changes in consciousness can indicate worsening brain injury or increased intracranial pressure, and prompt recognition is crucial for timely intervention.

Choice B reason:

A focal neurological exam is important but is more specific to identifying localized neurological deficits rather than detecting general deterioration. It is essential but secondary to monitoring the overall level of consciousness.

Choice C reason:

Body posturing can indicate severe brain injury or increased intracranial pressure, but it typically occurs later in the course of deterioration. Early changes in the level of consciousness are more sensitive indicators of a declining condition.

Choice D reason:

Vital signs are important to monitor, but changes in vital signs can occur later in the progression of a declining neurological status. Early detection of changes in the level of consciousness allows for more timely intervention.

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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

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Correct Answer is B

Explanation

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Correct Answer is A

Explanation

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