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

Explanation

Choice A reason:Swaying during a Romberg test indicates a positive result, suggesting proprioceptive deficits or sensory ataxia.

Choice B reason:Unequal pupil response to light relates to cranial nerve function, not balance assessed by the Romberg test.

Choice C reason: This is incorrect. Patient taking two attempts to touch their nose while their eyes are closed is a mild impairment of coordination, which may be due to neurologic changes or other factors such as fatigue or medication. This is not a significant finding that requires immediate attention.

Choice D reason: This is incorrect. Patient complaining of mild dizziness is a common symptom of neurologic changes or vestibular dysfunction. It is not a serious finding that requires immediate attention. The nurse should monitor the patient and provide comfort measures.

A. Hypoglossal - Cranial Nerve XII B. Trigeminal - Cranial Nerve V C. Facial - Cranial Nerve VII D. Vestibulocochlear - Cranial Nerve VIII

Correct Answer is A

Explanation

Choice A reason: The hypoglossal nerve is responsible for the movement of the tongue. It innervates the muscles of the tongue and allows for speech, swallowing, and chewing.

Choice B reason: The trigeminal nerve is responsible for the sensation and motor function of the face. It innervates the muscles of mastication, the skin of the face, and the mucous membranes of the mouth and nose.

Choice C reason: The facial nerve is responsible for the expression and taste of the face. It innervates the muscles of facial expression, the lacrimal and salivary glands, and the anterior two-thirds of the tongue.

Choice D reason: The vestibulocochlear nerve is responsible for the hearing and balance of the ear. It innervates the cochlea and the vestibular apparatus of the inner ear.

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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:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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