A patient with a neck fracture at the C3 level is admitted to the intensive care unit (ICU) following initial treatment in the emergency room. During the initial assessment of the patient, the nurse recognizes the presence of spinal shock on finding:

Flaccid paralysis and lack of sensation below the level of the injury

Hypotension, bradycardia, and warm extremities

Presence of hyperactive reflex activity below the level of the injury

Severe headache, hypertension, and flushed face

Answer and Explanation

The Correct Answer is A

Choice A reason:

Flaccid paralysis and lack of sensation below the level of the injury are classic signs of spinal shock. Spinal shock is characterized by a temporary loss of all reflexes, motor, and sensory activity below the level of injury, which typically occurs immediately following the injury. Recognizing these signs is crucial for the timely management of the condition.

Choice B reason:

Hypotension, bradycardia, and warm extremities are more indicative of neurogenic shock rather than spinal shock. Neurogenic shock results from the loss of sympathetic tone following a spinal cord injury, leading to cardiovascular changes. These signs do not specifically indicate spinal shock.

Choice C reason:

The presence of hyperactive reflex activity below the level of the injury is not associated with spinal shock. Spinal shock involves the loss of reflex activity rather than hyperactivity. Hyperactive reflexes might develop later as the spinal cord recovers from the initial shock phase.

Choice D reason:

Severe headache, hypertension, and flushed face are symptoms more commonly associated with autonomic dysreflexia, not spinal shock. Autonomic dysreflexia occurs in patients with spinal cord injuries at or above the T6 level and is a response to a noxious stimulus below the level of injury. These symptoms are not indicative of spinal shock.

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Correct Answer is A

Explanation

Choice A reason:

Arterial Blood Gas (ABG) analysis is the best method to determine the effectiveness of treatments in a client receiving mechanical ventilation. ABGs provide direct information about the patient's oxygenation, ventilation, and acid-base status, which are critical in managing acute respiratory failure.

Choice B reason:

While blood pressure is important for overall patient monitoring, it does not provide specific information about the effectiveness of ventilation and respiratory status. It is more related to hemodynamic stability.

Choice C reason:

Capillary refill can provide some information about peripheral perfusion but is not specific enough to assess the effectiveness of mechanical ventilation or respiratory treatments.

Choice D reason:

Heart rate is a vital sign that can indicate the patient's overall condition but does not specifically assess the effectiveness of ventilation or respiratory treatments. It should be considered along with other more specific respiratory assessments.

A. Soak the pin sites with alcohol pads B. Remove the vest when bathing the patient C. Assess the chest and back for skin breakdown D. Assess pin sites frequently for signs of infection E. Tape a halo wrench to the vest for emergencies

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

Explanation

Choice A reason:

Soaking the pin sites with alcohol pads is not recommended as it can dry out the skin and increase the risk of infection. Pin site care typically involves using saline or other recommended solutions to clean the area gently.

Choice B reason:

Removing the vest when bathing the patient is not recommended. The vest provides stability and support for the spinal fracture, and removing it can compromise the patient's safety. Alternative methods should be used to maintain hygiene without removing the vest.

Choice C reason:

Assessing the chest and back for skin breakdown is crucial in patients with a halo device to prevent pressure ulcers and other skin issues. Regular assessment helps identify any potential problems early.

Choice D reason:

Assessing pin sites frequently for signs of infection is essential to prevent complications. Infection at the pin sites can lead to serious issues, and frequent monitoring ensures any signs of infection are caught and treated promptly.

Choice E reason:

Taping a halo wrench to the vest is important for emergencies. The wrench is necessary to quickly remove the halo device if needed in an emergency situation, such as if the patient requires resuscitation.

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A patient with a neck fracture at the C3 level is admitted to the intensive care unit (ICU) following initial treatment in the emergency room. During the initial assessment of the patient, the nurse recognizes the presence of spinal shock on finding:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client in acute respiratory failure who is receiving mechanical ventilation. Which of the following assessments is the best method to determine the effectiveness of the current treatments?

Correct Answer is A

Explanation

The nurse is preparing to care for a patient with a spinal fracture who has a halo device in place. The nurse plans to implement the following orders:

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

Explanation

The nurse interprets which finding as an early sign of acute respiratory distress syndrome (ARDS) in a client at risk?

A nurse is caring for a patient who has a closed-head injury with ICP readings ranging from 16-22 mm Hg. What actions should the nurse take to decrease the potential for raising the client's ICP? Select all that apply.

Which assessment of a patient in shock would give the nurse the most valuable information to determine there is adequate tissue perfusion?

A nurse is caring for four patients in the neurologic intensive care unit. After receiving the hand-off report, which patient does the nurse see first?

After brain death has been determined, which of the following is a priority nursing action in caring for an organ donor?

The nurse is caring for a patient who is on mechanical ventilation and the high pressure alarm is sounding. Which of the following is the most likely cause?

A nurse assesses a patient who experienced a spinal cord injury at the T5 level 24 hours ago. Which manifestations would the nurse correlate with neurogenic shock? Select all that apply.

The nurse receives new orders for multiple clients. Which order should be the nurse's priority?