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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Suctioning can increase ICP due to the Valsalva response and should only be done if absolutely necessary.
B. Documenting without intervention could lead to worsening of the patient's condition.
C. Notifying the physician and raising the head of the bed helps to reduce ICP by promoting venous drainage. An ICP of 30 mmHg is critically high, requiring immediate intervention to prevent further damage.
D. Lowering the head of the bed can increase ICP further; head elevation is recommended to improve cerebral drainage.
Correct Answer is C
Explanation
A. Surgery to remove the eye is not the immediate course of action and is only considered in severe cases where infection cannot be managed.
B. Referral for a drug rehabilitation program is beneficial for the patient's long-term health but is not the priority in this case where there is an active eye infection.
C. Admission for IV and intravitreal antibiotics is necessary to treat a possible severe eye infection, which can be sight-threatening, especially in immunocompromised patients, such as those with a history of IV drug use.
D. An outpatient follow-up with an eye specialist may be part of ongoing care but does not address the acute need for immediate antibiotic therapy to prevent further complications.
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