The nurse assists with the prehospital care of a patient who experienced a 15-foot fall. Which action by the nurse will limit the damage if a spinal cord injury (SCI) has occurred?
Initiating an IV access peripherally
Maintaining an open airway using the head tilt method
Determining whether the patient is oriented to person, place, and time
Applying a rigid cervical collar and using a backboard to transport the patient
The Correct Answer is D
A. IV access is important for fluid administration but does not prevent further spinal injury.
B. The head tilt method can worsen a cervical spine injury; instead, a jaw-thrust maneuver should be used to open the airway without neck movement.
C. Assessing orientation is part of the neurological exam but does not prevent further injury.
D. Applying a rigid cervical collar and using a backboard immobilizes the spine, preventing further spinal cord damage during transport.
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Related Questions
Correct Answer is D
Explanation
A. IV access is important for fluid administration but does not prevent further spinal injury.
B. The head tilt method can worsen a cervical spine injury; instead, a jaw-thrust maneuver should be used to open the airway without neck movement.
C. Assessing orientation is part of the neurological exam but does not prevent further injury.
D. Applying a rigid cervical collar and using a backboard immobilizes the spine, preventing further spinal cord damage during transport.
Correct Answer is B
Explanation
A. Headache is a common symptom but subjective and less reliable as an early sign of increased ICP.
B. Altered level of consciousness is the most sensitive and reliable early clinical indicator of increased ICP, reflecting impaired brain function.
C. Vital signs may remain stable initially; changes often occur later in the course of increased ICP.
D. Increased motor function is unlikely; motor deficits or decreased motor response are more common with increased ICP.
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