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 C

Explanation

A. Avoiding sexual intercourse under the influence of drugs reduces certain risks but does not address the specific risk of needle transmission.

B. Asking others to be tested for HIV may be unrealistic and does not prevent HIV transmission through shared equipment.

C. Participating in a needle exchange program reduces the risk of HIV transmission by providing sterile needles, lowering the likelihood of infection from shared or contaminated needles.

D. Cleaning needles with betadine is not effective for HIV prevention; only sterile, unused needles should be used.

A. Encourage the patient to cough to expectorate secretions B. Elevate the head of the bed to 30-45 degrees C. Stimulate the patient with active range of motion exercises D. Perform serial neurologic assessments while hospitalized E. Contact the healthcare provider if the ICP is sustained between 30-40mmHg

Correct Answer is ["B","D","E"]

Explanation

A. Coughing can increase ICP by increasing intrathoracic pressure and should be minimized in patients with head injuries.

B. Elevating the head of the bed to 30-45 degrees promotes venous drainage from the head, reducing ICP.

C. Active stimulation can increase ICP and is generally avoided in patients with acute head injuries.

D. Serial neurologic assessments help monitor any changes in the patient’s condition and ICP, allowing for timely intervention.

E. Sustained ICP levels between 30-40 mmHg are significantly elevated and require immediate communication with the healthcare provider, as they are above the normal range and could lead to further complications

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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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A 24-year-old patient who is an intravenous drug user asks the nurse about preventing acquired immunodeficiency syndrome (AIDS). The nurse informs the patient that the risk of developing the human immunodeficiency virus (HIV) infection from drug use can be reduced by:

Correct Answer is C

Explanation

The nurse has established a goal to maintain intracranial pressure (ICP) within the normal range for the patient with an acute head injury. Which action(s) should the nurse take to achieve this goal? (SELECT ALL THAT APPLY)

Correct Answer is ["B","D","E"]

Explanation

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