A patient presents to the emergency department with a cervical spinal cord injury immediately after a motor vehicle crash. What should the nurse explain to the family as the reason for the patient being placed on mechanical ventilation? The:

accident injured the patient's lungs.

patient has a history of smoking.

nerves that control the lung function have been injured.

patient is unable to breathe because he is unconscious.

Answer and Explanation

The Correct Answer is C

A. While lung injury could occur in traumatic situations, it is not the primary reason for mechanical ventilation in the context of a spinal cord injury.

B. A history of smoking may affect lung health but does not directly justify the immediate need for mechanical ventilation following a spinal cord injury.

C. The nerves that control lung function may be injured in a cervical spinal cord injury, particularly at higher levels like C3-C5, leading to respiratory muscle paralysis and necessitating mechanical ventilation to support breathing.

D. While unconsciousness may complicate breathing, the primary concern is the loss of function in the spinal cord nerves controlling respiration.

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Correct Answer is A

Explanation

A. Standard precautions should be used for all patients, including those with AIDS, as they are designed to prevent the transmission of infections regardless of the patient's diagnosis. This includes the use of gloves, hand hygiene, and proper disposal of sharps.

B. Droplet precautions are specific to diseases that are spread through respiratory droplets, which is not the primary concern in AIDS management.

C. Contact precautions are used for infections that can be transmitted through direct contact with the patient or contaminated surfaces, but are not routinely required for AIDS patients unless they have co-infections.

D. Behavioral precautions are not a recognized category for infection control in clinical settings.

A. Administer antibiotics due to increased risk of infection B. Prevent the drainage by applying a pressure dressing C. Hang intravenous (IV) fluids to replace fluids lost D. Allow fluid to drain from the patient's ear onto gauze and notify provider

Correct Answer is D

Explanation

A. Antibiotics may be necessary if infection is confirmed, but this is not the priority action.

B. Applying a pressure dressing could increase intracranial pressure or worsen the injury.

C. IV fluids can be helpful in managing shock but are not directly related to CSF leakage management.

D. Yellowish fluid from the ear, which creates a "halo" or yellow ring around it on gauze, may indicate cerebrospinal fluid (CSF) leakage. This is a sign of a potential skull fracture and requires prompt provider notification. Allowing the fluid to drain and collecting it can provide necessary information about the injury.

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A patient presents to the emergency department with a cervical spinal cord injury immediately after a motor vehicle crash. What should the nurse explain to the family as the reason for the patient being placed on mechanical ventilation? The:

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Correct Answer is D

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