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. While anxiety can cause gastrointestinal symptoms, the context of this patient’s experience with seizures indicates that it is specifically related to the seizure disorder rather than an independent anxiety issue.

B. The sensation of "butterflies" is not typically related to hunger, as hunger is more commonly associated with physical feelings of emptiness or pain rather than a specific butterfly sensation.

C. An aura is a perceptual disturbance experienced by some patients with seizure disorders that precedes a seizure. It can manifest as various sensations, including gastrointestinal feelings like "butterflies," which serve as a warning sign that a seizure is imminent.

D. A postictal sign refers to the state of confusion or altered consciousness following a seizure, rather than sensations experienced prior to the seizure.

A. T 92.5 F (33.6 C), BP 90/64, HR 80, RR 14, 02 Sat 97% Room Air B. T 98.7 F (36.4 C), BP 220/46, HR 30, RR 6, O2 Sat 98% Room Air C. T 98.6 F (37 C), BP 200/94, HR 90, RR 18, 02 Sat 100% Room Air D. T 103.1 F (39.5 C), BP 82/50, HR 132, RR 30, O2 Sat 99% Room Air

Correct Answer is B

Explanation

A. The low blood pressure (90/64) may indicate hypovolemia or shock but is not specific for ICP concerns.

B. This set of vital signs is concerning due to the extremely high blood pressure (220/46) combined with a very low heart rate (30) and low respiratory rate (6), which can indicate an autonomic response to increased ICP, potentially leading to Cushing's triad (hypertension, bradycardia, and irregular respirations).

C. Although the blood pressure is high (200/94), the heart rate is normal and the respiratory rate is stable, making this less alarming compared to option B.

D. The elevated temperature and abnormal heart rate (132) indicate potential fever and tachycardia, but the blood pressure (82/50) is low and does not directly indicate increased ICP.

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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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Naxlex Comprehensive Predictor Exams

A patient diagnosed with a seizure disorder tells the nurse that they feel like they have "butterflies" in their stomach. The patient has felt this in the past before having a seizure. The nurse recognizes that this feeling is:

Correct Answer is C

Explanation

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Correct Answer is B

Explanation

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