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 C

Explanation

A. While drug dependence can be a concern with long-term use, it is not the immediate priority in an emergency setting where the goal is to stabilize the patient in status epilepticus.

B. Cardiac rhythm monitoring is important when administering certain medications, but lorazepam primarily affects the central nervous system and respiratory system, making oxygen saturation monitoring more critical.

C. Pulse oximetry is the priority assessment as IV lorazepam can depress the respiratory system, leading to hypoxia. Monitoring oxygen saturation helps ensure the patient maintains adequate respiratory function during administration.

D. Assessing pain is important in patient care, but it is not the priority in managing a patient in status epilepticus, where stabilization is essential.

A. Fifth intercostal space, left midclavicular line B. Fourth intercostal space, right sternal boarder C. Third intercostal space, left midclavicular line D. Second intercostal space, right sternal boarder

Correct Answer is A

Explanation

A. The fifth intercostal space at the left midclavicular line is the location of the mitral valve, where murmurs associated with mitral valve disease are best auscultated.

B. The fourth intercostal space at the right sternal border is the location for assessing the tricuspid valve, not the mitral valve.

C. The third intercostal space at the left midclavicular line is not associated with loudest auscultation of the mitral valve murmur.

D. The second intercostal space at the right sternal border is where the aortic valve sounds are best heard.

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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 healthcare provider has prescribed intravenous (IV) lorazepam for the patient in status epilepticus. During administration, which is the priority assessment by the nurse?

Correct Answer is C

Explanation

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Correct Answer is A

Explanation

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