The nurse is caring for a patient who sustained a spinal cord injury (SCI) at T1. The alarm on the monitor sounds because the patient's blood pressure is 86/50 and the heart rate is 44. The nurse's priority action would be to:

assess the patient's neurological status and repeat vital signs

ask the patient care tech to check on the patient.

place the client in reverse Trendelenburg position.

administer intravenous (tv) fluids to increase cardiac output.

Answer and Explanation

The Correct Answer is A

A) Assess the patient's neurological status and repeat vital signs:
In patients with a spinal cord injury (SCI) at T1, autonomic dysreflexia or neurogenic shock can lead to unstable vital signs, including hypotension and bradycardia. The most immediate concern in this scenario is to determine if the patient is experiencing neurogenic shock, which can result from the loss of sympathetic nervous system function below the level of the injury. By assessing the patient’s neurological status (such as checking for changes in motor function, sensation, or level of consciousness) and repeating vital signs, the nurse can gather the necessary data to make informed decisions about further interventions.

B) Ask the patient care tech to check on the patient:
While the patient care tech can assist with tasks, this is not the priority action. The nurse must immediately assess the patient's condition, particularly given the vital sign changes and the potential for a life-threatening situation like neurogenic shock. The nurse's clinical judgment and expertise are required to evaluate the situation appropriately.

C) Place the client in reverse Trendelenburg position:
Placing the patient in reverse Trendelenburg may help with hypotension in certain situations, but it is not the priority intervention for someone with a spinal cord injury at T1. In cases of neurogenic shock or autonomic dysreflexia, positioning alone will not correct the underlying issue.

D) Administer intravenous (IV) fluids to increase cardiac output:
While IV fluids may be necessary to treat hypotension in some situations, the nurse must first assess the patient’s neurological status and repeat vital signs to determine the cause of the hypotension and bradycardia. Administering IV fluids without understanding the underlying cause could be inappropriate or even harmful, particularly if the low blood pressure is related to neurogenic shock, which requires careful management.

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Correct Answer is C

Explanation

A) Equal but sluggishly reactive pupils:
Pupillary changes, including sluggish or unequal responses, are significant signs of increasing intracranial pressure (ICP) and should be monitored closely. However, altered level of consciousness (LOC) is typically one of the earliest signs of increased ICP. The response of the pupils to light can become abnormal later, once pressure increases within the brain, particularly when brainstem function is impacted.

B) Widening pulse pressure:
A widening pulse pressure is part of Cushing’s triad, which is a late sign of increased ICP. Cushing’s triad consists of hypertension, bradycardia, and irregular respirations (often seen as Cheyne-Stokes). These changes occur in the later stages of elevated ICP as a compensatory mechanism to preserve cerebral perfusion. While this is an important finding, altered LOC would precede the development of Cushing’s triad.

C) Altered level of consciousness:
Altered level of consciousness (LOC) is typically the first and most sensitive indicator of increased ICP. As pressure increases within the skull, it compresses brain tissue and affects the brainstem, which controls basic functions like consciousness. LOC can range from mild confusion and disorientation to full loss of consciousness or coma, depending on the severity of the ICP increase.

D) Tachycardia and hypotension:
Tachycardia and hypotension can be associated with shock or other conditions, but they are not characteristic of early increased ICP. In fact, as ICP rises, the body typically responds with bradycardia (slower heart rate) and hypertension (increased blood pressure), which are part of the compensatory mechanisms.

A. there are no obvious symptoms or problems B. radiation therapy is ineffective because the ovaries are located so deep within the pelvis C. the causative cancer cell is resistant to chemotherapy or radiation D. ovarian cancer occurs primarily among women over age 70 that also have other complicating health problems

Correct Answer is ["A"]

Explanation

A) There are no obvious symptoms or problems: Ovarian cancer is often referred to as the "silent killer" because it tends to develop without noticeable symptoms in the early stages. When symptoms do appear, they are often vague and nonspecific, such as bloating, abdominal discomfort, or changes in bowel habits. By the time ovarian cancer is diagnosed, it is frequently at an advanced stage, making it more difficult to treat effectively. This lack of early, clear symptoms contributes significantly to the high death rate associated with the disease.

B) Radiation therapy is ineffective because the ovaries are located so deep within the pelvis: While ovarian cancer is located deep within the pelvis, radiation therapy can still be effective for certain types of tumors. However, the primary reason for high death rates is not the location of the ovaries, but the late-stage diagnosis and difficulty in detecting the cancer early.

C) The causative cancer cell is resistant to chemotherapy or radiation: While some ovarian cancer cells may exhibit resistance to treatment, this is not the main reason for the high mortality rate. The real issue is the lack of early detection, as ovarian cancer is often diagnosed when it has already spread beyond the ovaries. Early-stage ovarian cancer may be more responsive to treatment, but by the time symptoms are noticeable, the cancer is often advanced, which limits the effectiveness of chemotherapy and radiation.

D) Ovarian cancer occurs primarily among women over age 70 that also have other complicating health problems: Although the incidence of ovarian cancer increases with age, particularly after age 60, it is not the primary factor contributing to high death rates. Many women diagnosed with ovarian cancer are relatively healthy except for the cancer itself.

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The nurse is caring for a patient who sustained a spinal cord injury (SCI) at T1. The alarm on the monitor sounds because the patient's blood pressure is 86/50 and the heart rate is 44. The nurse's priority action would be to:

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In educating clients about ovarian cancer the nurse emphasizes death rates for ovarian cancer are high because:

Correct Answer is ["A"]

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