The client is brought to the ER after falling off a roof and landing on his back. A T4 spinal fracture is diagnosed. The client's blood pressure is 74/40 mmHg, pulse is 55/min, and skin is pink and dry. What of the following nursing actions is a priority?
Determine if blood is present in urine
Perform a neurological assessment
Administer IV normal saline
Perform a 12-lead electrocardiogram
The Correct Answer is C
Choice A rationale: Although important to assess for potential kidney injury, addressing hypotension due to potential spinal shock takes priority.
Choice B rationale: Important for determining any neurological deficits, but addressing hypotension is the initial priority.
Choice C rationale: Hypotension indicates potential spinal shock or hemorrhagic shock, and fluid resuscitation is the immediate priority to stabilize the client's blood pressure.
Choice D rationale: While important for assessing cardiac status, addressing hypotension takes precedence to stabilize the client's condition.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale: The Tensilon test involves injecting edrophonium, and in myasthenia gravis, temporary improvement in muscle strength confirms the diagnosis by demonstrating increased acetylcholine activity at the neuromuscular junction.
Choice B rationale: This describes the pathophysiology of myasthenia gravis but doesn’t directly confirm the diagnosis via the Tensilon test.
Choice C rationale: While this may be seen in myasthenia gravis, the Tensilon test specifically aims to observe improved muscle strength after administration.
Choice D rationale: While the presence of these antibodies is a characteristic of myasthenia gravis, the Tensilon test is used to assess the immediate response to the medication for diagnostic confirmation.
Correct Answer is D
Explanation
Choice A rationale: Tachycardia and petechiae over the chest wall and buccal membranes are signs of fat embolism syndrome, another complication of fractures that occurs when fat globules enter the bloodstream and obstruct pulmonary vessels.
Choice B rationale: Positive Homan's sign with calf tenderness and warmth are signs of deep vein thrombosis, a condition that can occur after prolonged immobilization or surgery.
Choice C rationale: Acute cough, cyanosis, and decreased blood pressure are signs of pulmonary embolism, a life-threatening condition that occurs when a blood clot travels to the lungs and blocks blood flow.
Choice D rationale: These are signs of compartment syndrome, which is a serious complication of fractures that occurs when increased pressure within a closed space compromises blood flow and tissue perfusion. Compartment syndrome can lead to ischemia, necrosis, and nerve damage if not treated promptly.
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