Immediately following a spinal cord injury, a patient asks about the extent of impairment that will result from the injury. The best response by the nurse is:

The extent of your injury cannot be determined until any secondary injury to the cord has resolved.

An MRI can reveal the extent of cord damage.

You will have normal function when spinal shock resolves and the reflex arc returns.

Because rehabilitation can affect the return of function, it will be years before impairment can be determined.

Answer and Explanation

The Correct Answer is A

Choice A reason:

The extent of impairment following a spinal cord injury cannot be determined until any secondary injury to the cord has resolved. Secondary injury, such as inflammation and swelling, can worsen the initial damage and impact the long-term prognosis.

Choice B reason:

An MRI can reveal the extent of cord damage but does not provide a complete picture of the potential functional outcomes. The full extent of impairment cannot be determined solely by imaging.

Choice C reason:

Stating that the patient will have normal function when spinal shock resolves and the reflex arc returns is misleading and overly optimistic. Not all patients will regain normal function after a spinal cord injury, and outcomes vary.

Choice D reason:

While rehabilitation plays a crucial role in recovery, stating that it will be years before impairment can be determined is not entirely accurate. Functional outcomes can often be assessed sooner as the initial recovery phase progresses.

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Correct Answer is A

Explanation

Choice A reason:

Assessing the level of consciousness is the most important nursing assessment for detecting early signs of a declining condition in a patient with a severe concussion. Changes in consciousness can indicate worsening brain injury or increased intracranial pressure, and prompt recognition is crucial for timely intervention.

Choice B reason:

A focal neurological exam is important but is more specific to identifying localized neurological deficits rather than detecting general deterioration. It is essential but secondary to monitoring the overall level of consciousness.

Choice C reason:

Body posturing can indicate severe brain injury or increased intracranial pressure, but it typically occurs later in the course of deterioration. Early changes in the level of consciousness are more sensitive indicators of a declining condition.

Choice D reason:

Vital signs are important to monitor, but changes in vital signs can occur later in the progression of a declining neurological status. Early detection of changes in the level of consciousness allows for more timely intervention.

A. Apply oxygen at 100%. B. Assess the heart rate. C. Ensure a patent airway. D. Start two large-bore IV lines.

Correct Answer is C

Explanation

Choice A reason:

Applying oxygen at 100% is an important step in managing a patient with a life-threatening chest injury. However, ensuring a patent airway is the first priority, as it is crucial to maintain airway patency to facilitate oxygen delivery. Without an open airway, oxygen administration would be ineffective.

Choice B reason:

Assessing the heart rate is part of the initial assessment in emergency care. However, the priority is to ensure a patent airway, as a compromised airway can lead to hypoxia and rapid deterioration of the patient's condition. Heart rate assessment can follow once airway patency is confirmed.

Choice C reason:

Ensuring a patent airway is the top priority in the emergency management of a patient with a life-threatening chest injury. Airway patency is essential for effective ventilation and oxygenation. If the airway is obstructed, the patient cannot receive oxygen or expel carbon dioxide, leading to life-threatening complications.

Choice D reason:

Starting two large-bore IV lines is important for fluid resuscitation and medication administration. However, the primary focus should be on ensuring a patent airway, as immediate airway management is critical to the patient's survival in the acute phase of a life-threatening chest injury.

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Immediately following a spinal cord injury, a patient asks about the extent of impairment that will result from the injury. The best response by the nurse is:

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Naxlex Comprehensive Predictor Exams

The nurse is assessing a teenager recently admitted with a severe concussion from playing football. Which is the most important nursing assessment to detect early signs of a declining condition?

Correct Answer is A

Explanation

A patient has been brought to the emergency department with a life-threatening chest injury. What action by the nurse takes priority?

Correct Answer is C

Explanation

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Immediately following a spinal cord injury, a patient asks about the extent of impairment that will result from the injury. The best response by the nurse is:

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