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","D","E"]

Explanation

Choice A reason: Lethargy is a sign of increased intracranial pressure (ICP), as it indicates a decreased level of alertness and responsiveness due to brain compression¹².
Choice B reason: Slowed responses to verbal cues are a sign of increased ICP, as they indicate a decreased level of cognitive function and communication ability due to brain compression¹².
Choice C reason: Negative Babinski sign is not a sign of increased ICP, as it indicates a normal reflex response of the toes to stimulation of the sole of the foot³. A positive Babinski sign, where the big toe extends upward and the other toes fan out, is a sign of neurological damage, but not necessarily increased ICP³.
Choice D reason: Altered speech is a sign of increased ICP, as it indicates a decreased level of language function and articulation due to brain compression¹².
Choice E reason: Decreased level of consciousness is a sign of increased ICP, as it indicates a decreased level of awareness and arousal due to brain compression¹².

A. Apples, oranges and strawberries B. Tuna fish, white bread and green vegetables C. Lean beef, raisins and prunes D. White chicken meat, whole milk and rice

Correct Answer is C

Explanation

Choice A reason: This is incorrect. Apples, oranges and strawberries are good sources of vitamin C, which can help with iron absorption, but they are not high in iron content themselves. The patient should eat foods that are rich in both iron and vitamin C.

Choice B reason: This is incorrect. Tuna fish, white bread and green vegetables are not high in iron content either. Tuna fish is a source of protein, but it has less iron than other types of meat or fish. White bread is refined and has less iron than whole grain bread. Green vegetables have some iron, but not enough to meet the daily requirements.

Choice C reason: This is correct. Lean beef, raisins and prunes are high in iron content and can help the patient with iron deficiency anemia. Lean beef is a source of heme iron, which is more easily absorbed by the body than non-heme iron from plant sources. Raisins and prunes are dried fruits that have more iron than fresh fruits.

Choice D reason: This is incorrect. White chicken meat, whole milk and rice are not high in iron content either. White chicken meat has less iron than dark chicken meat or red meat. Whole milk is a source of calcium, which can interfere with iron absorption. Rice is a source of carbohydrates, but it has less iron than other grains or legumes.

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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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Explanation

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Correct Answer is C

Explanation

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