An emergency room nurse initiates care for a patient with a spinal cord injury at their cervical 5 vertebra after a motor vehicle accident. Select the nurse's critical focus of care:

Assessment of arms and legs movement

Evaluation of knee jerk reflex

Measurement of vital signs

Evaluation of respiratory status

Answer and Explanation

The Correct Answer is D

Choice A reason: Assessment of arms and legs movement is an important part of the neurological assessment, but it is not the critical focus of care for a patient with a spinal cord injury at the cervical 5 vertebra. This level of injury affects the phrenic nerve, which controls the diaphragm and breathing. The patient may have difficulty breathing or require mechanical ventilation.

Choice B reason: Evaluation of knee jerk reflex is not the critical focus of care for a patient with a spinal cord injury at the cervical 5 vertebra. The knee jerk reflex is controlled by the spinal cord segments L2-L4, which are below the level of injury. The patient may have normal or exaggerated reflexes, depending on the extent of the spinal cord damage.

Choice C reason: Measurement of vital signs is a routine part of the nursing care, but it is not the critical focus of care for a patient with a spinal cord injury at the cervical 5 vertebra. The patient may have abnormal vital signs due to the injury, such as low blood pressure, slow heart rate, or irregular temperature. However, these are not as life-threatening as respiratory failure.

Choice D reason: Evaluation of respiratory status is the critical focus of care for a patient with a spinal cord injury at the cervical 5 vertebra. The patient is at high risk of respiratory compromise due to the impairment of the phrenic nerve and the diaphragm. The nurse should monitor the patient's oxygen saturation, respiratory rate, depth, and rhythm, and provide oxygen therapy or mechanical ventilation as needed. The nurse should also assess the patient for signs of respiratory infection, such as fever, cough, or sputum.

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Correct Answer is ["A","B","C","E"]

Explanation

Choice A reason: Diplopia, or double vision, is a symptom of multiple sclerosis that results from damage to the optic nerve or the brainstem. It can affect one or both eyes, and it can cause difficulty with reading, driving, and other activities that require visual coordination.

Choice B reason: Fatigue that worsens with heat is a symptom of multiple sclerosis that occurs due to the impaired transmission of nerve impulses in the central nervous system. Heat can exacerbate this impairment and make the patient feel more tired, weak, and sluggish.

Choice C reason: Muscle weakness, spasticity, tremors are symptoms of multiple sclerosis that result from damage to the motor pathways in the brain and spinal cord. They can affect the patient's mobility, balance, coordination, and speech.

Choice D reason: Orthostatic hypotension, or a sudden drop in blood pressure when standing up, is not a common symptom of multiple sclerosis. It can be caused by other conditions, such as dehydration, anemia, or heart problems.

Choice E reason: Numbness and tingling are symptoms of multiple sclerosis that result from damage to the sensory pathways in the brain and spinal cord. They can affect any part of the body, but they are more common in the limbs, face, and trunk.

A. Elevate the head of the bed 20 to 30 degrees. B. Maintain bright lighting in the room to assess bleeding at the surgical site. C. Stimulate the patient every half hour to assess changes in level of consciousness. D. Allow the patient to change positions frequently to maintain comfort.

Correct Answer is A

Explanation

Choice A reason: Elevating the head of the bed 20 to 30 degrees is an appropriate intervention for a patient who had a craniotomy to relieve increased intracranial pressure. It helps to reduce the venous pressure and improve the cerebral perfusion.

Choice B reason: Maintaining bright lighting in the room to assess bleeding at the surgical site is not an appropriate intervention for a patient who had a craniotomy to relieve increased intracranial pressure. It can increase the sensory stimulation and aggravate the intracranial pressure. The nurse should use dim lighting and monitor the dressing and the drainage system for signs of bleeding.

Choice C reason: Stimulating the patient every half hour to assess changes in level of consciousness is not an appropriate intervention for a patient who had a craniotomy to relieve increased intracranial pressure. It can increase the cerebral metabolic demand and worsen the intracranial pressure. The nurse should assess the level of consciousness using the Glasgow Coma Scale and avoid unnecessary stimulation.

Choice D reason: Allowing the patient to change positions frequently to maintain comfort is not an appropriate intervention for a patient who had a craniotomy to relieve increased intracranial pressure. It can increase the intrathoracic pressure and affect the cerebral blood flow. The nurse should limit the patient's movement and avoid extreme flexion, extension, or rotation of the head and neck.

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An emergency room nurse initiates care for a patient with a spinal cord injury at their cervical 5 vertebra after a motor vehicle accident. Select the nurse's critical focus of care:

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Naxlex Comprehensive Predictor Exams

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Explanation

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Correct Answer is A

Explanation

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