The nurse is assessing a 28-year-old client who sustained a spinal injury after diving into a shallow pool. Which finding would indicate that the client has a C-1 to C-2 injury?

The client is able to sit erect without assistance

The client is able to move fingers slightly

The client is displaying shallow respirations

The client is able to speak in full sentences

Answer and Explanation

The Correct Answer is C

A. The client is able to sit erect without assistance: This suggests a lower level injury, likely below C-2, as higher injuries often result in paralysis of respiratory muscles.

B. The client is able to move fingers slightly: This would be indicative of a higher level injury, but C-1 to C-2 injuries typically result in complete paralysis below the neck.

C. The client is displaying shallow respirations: Injuries at the C-1 or C-2 level can affect the diaphragm and the ability to breathe deeply, leading to shallow respirations.

D. The client is able to speak in full sentences: A C-1 to C-2 injury would likely affect the ability to speak, as it could impair the phrenic nerve and respiratory muscles needed for adequate breathing and speech.

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Correct Answer is C

Explanation

A. Insertion of central venous access: This is not relevant to compartment syndrome management. Central venous access is used for fluid administration or monitoring central venous pressure.

B. Phlebotomy: This is unrelated to the management of compartment syndrome, as it involves drawing blood and does not address the increased pressure.

C. Fasciotomy: Compartment syndrome is a medical emergency where increased pressure within a closed compartment compromises circulation and tissue function. A fasciotomy involves surgically opening the compartment to relieve the pressure, prevent tissue necrosis, and save the limb. This is the definitive treatment.

D. Insertion of arterial line: While this may be useful for monitoring blood pressure in critical situations, it does not relieve compartment syndrome.

A. Sinus rhythm with first-degree heart block B. ST-segment elevation myocardial infarction (STEMI) C. Atrial fibrillation D. Ventricular tachycardia

Correct Answer is B

Explanation

A. Sinus rhythm with first-degree heart block: This rhythm is characterized by a regular sinus rhythm with a prolonged PR interval (greater than 0.20 seconds), indicating a first-degree heart block.

B. ST-segment elevation myocardial infarction (STEMI): STEMI is indicated by significant ST-segment elevation in specific leads, showing acute myocardial infarction.

C. Atrial fibrillation: Atrial fibrillation shows an irregularly irregular rhythm without distinct P waves.

D. Ventricular tachycardia: Ventricular tachycardia is a rapid heart rhythm originating from the ventricles, with wide QRS complexes and no preceding P waves.

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The nurse is assessing a 28-year-old client who sustained a spinal injury after diving into a shallow pool. Which finding would indicate that the client has a C-1 to C-2 injury?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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