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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: "Try relaxation and warm moist compresses for your headaches and document your response." is not the best instruction by the nurse to gather additional data before the appointment. It is a suggestion for self-care and pain relief, but it does not provide any information about the cause, type, or severity of the headaches.
Choice B reason: "Keep a diary of your headaches, recording symptoms, timing, and headache triggers." is the best instruction by the nurse to gather additional data before the appointment. It is a useful tool for collecting objective and subjective data about the headaches, such as their frequency, duration, intensity, location, quality, associated symptoms, and precipitating factors. This can help the primary care practitioner to diagnose the type of headache, such as migraine, tension, or cluster, and prescribe the appropriate treatment.
Choice C reason: "Call and come in the next time you have a headache so you can be examined." is not the best instruction by the nurse to gather additional data before the appointment. It is a suggestion for urgent care, but it does not provide any information about the history, pattern, or characteristics of the headaches.
Choice D reason: "Keep track of how many headaches you have before you come in." is not the best instruction by the nurse to gather additional data before the appointment. It is a simple measure of the quantity of the headaches, but it does not provide any information about the quality, severity, or triggers of the headaches.
Correct Answer is D
Explanation
Choice A reason: This is not a correct explanation for the large number of leukemic white cells. Leukemic white cells are abnormal white blood cells that do not function properly. They do not attempt to take over the function of the abnormal white blood cells, but rather crowd out the normal ones.
Choice B reason: This is also not a correct explanation for the large number of leukemic white cells. Leukemic white cells do not help to protect against infection, but rather increase the risk of infection. They impair the immune system's ability to fight off bacteria, viruses, and other pathogens.
Choice C reason: This is a partially correct explanation for the large number of leukemic white cells. Leukemic white cells are larger in size than normal white blood cells, and they can clog the bone marrow. This can interfere with the production of other blood cells, such as red blood cells and platelets. However, this is not the only reason for the large number of leukemic white cells.
Choice D reason: This is the best explanation for the large number of leukemic white cells. Leukemic white cells are not as effective as normal white cells to protect against infection, because they are immature and dysfunctional. They do not respond to signals from the immune system, and they do not recognize or destroy foreign invaders. They also prevent the normal white cells from doing their job.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.