The nurse is caring for a patient in the acute care setting with a spinal cord injury (SCI) at the level of C-3. What is the main cause of complications or death related to this injury?

Bradycardia

Sepsis

Hypertension

Respiratory compromise

Answer and Explanation

The Correct Answer is D

A. Bradycardia is possible due to autonomic dysfunction but is not the leading cause of death.

B. Sepsis can occur due to immobility and pressure injuries but is secondary to respiratory compromise.

C. Hypertension is not directly linked to high cervical spine injuries and is less common than respiratory issues in this setting.

D. Respiratory compromise is the primary cause of complications or death in patients with a high cervical spine injury (C-3 and above) due to loss of innervation to the diaphragm and intercostal muscles, which impairs spontaneous breathing. Mechanical ventilation is often required to maintain adequate oxygenation.

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Correct Answer is B

Explanation

A. The low blood pressure (90/64) may indicate hypovolemia or shock but is not specific for ICP concerns.

B. This set of vital signs is concerning due to the extremely high blood pressure (220/46) combined with a very low heart rate (30) and low respiratory rate (6), which can indicate an autonomic response to increased ICP, potentially leading to Cushing's triad (hypertension, bradycardia, and irregular respirations).

C. Although the blood pressure is high (200/94), the heart rate is normal and the respiratory rate is stable, making this less alarming compared to option B.

D. The elevated temperature and abnormal heart rate (132) indicate potential fever and tachycardia, but the blood pressure (82/50) is low and does not directly indicate increased ICP.

Correct Answer is ["0.5"]

Explanation

To administer the correct dose of Morphine, the nurse needs to calculate the volume of medication to deliver 1 mg of Morphine. Since the medication is supplied in a concentration of 2 mg per 1 mL, the nurse would administer half of the volume of the vial to provide the ordered 1 mg dose. Therefore, the nurse should administer 0.5 mL of Morphine to the patient.

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The nurse is caring for a patient in the acute care setting with a spinal cord injury (SCI) at the level of C-3. What is the main cause of complications or death related to this injury?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a patient with an acute brain injury. Which of the following sets of vital signs would concern the nurse about increasing intracranial pressure (ICP)?

Correct Answer is B

Explanation

A patient is ordered 1 mg of Morphine IV push. The medication is supplied in vials 2 mg/1 mL. What should the nurse administer? (round to the nearest tenth)

Correct Answer is ["0.5"]

Explanation

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