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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale: Conus medullaris syndrome involves injury or compression to the end portion of the spinal cord and can present with various symptoms but not necessarily lack of normal sympathetic outflow leading to shock.
Choice B rationale: Concussion is a mild traumatic brain injury, and the symptoms described align more with spinal cord injury leading to neurogenic shock.
Choice C rationale: Neurogenic shock occurs due to the loss of sympathetic tone and is characterized by bradycardia, low blood pressure, and vasodilation following spinal cord injury at or above the level of the sixth thoracic vertebra.
Choice D rationale: Diffuse axonal injury typically presents with more widespread brain injury-related symptoms and is not associated with the specific spinal cord-related symptoms described.
Correct Answer is B
Explanation
Choice A rationale: Used primarily for gout and familial Mediterranean fever, not for Paget's disease.
Choice B rationale: Alendronate is a bisphosphonate commonly used to manage Paget's disease by slowing down bone breakdown and reducing the risk of complications.
Choice C rationale: Prednisone is a corticosteroid used for various inflammatory conditions but not typically prescribed for Paget's disease.
Choice D rationale: Used to lower uric acid levels and prevent gout attacks, not a primary medication for Paget's disease.
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