The nurse is caring for a patient who was in a motor vehicle accident that resulted in cervical trauma to C4. Which assessment is the priority?
Respirations
Pulse
Temperature
Blood Pressure
The Correct Answer is A
A. Respirations: C4 injuries compromise the phrenic nerve, which controls the diaphragm. A high cervical spine injury can lead to respiratory failure, making airway and breathing the top priority.
B. Pulse: While monitoring circulation is important, breathing takes priority in a C4 injury due to the risk of respiratory paralysis.
C. Temperature: Temperature regulation may be affected due to autonomic dysfunction, but airway and breathing remain the priority.
D. Blood Pressure: While spinal cord injuries can cause neurogenic shock (low BP, bradycardia), ensuring airway and breathing comes first.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. "If I develop atelectasis, I will need a chest tube to drain excess fluid." Atelectasis is alveolar collapse, not fluid accumulation. Chest tubes are used for pneumothorax or pleural effusion, not for atelectasis.
B. "Hyperventilation will open up my alveoli, preventing atelectasis." Hyperventilation can cause respiratory alkalosis but does not effectively re-expand alveoli. Incentive spirometry and deep breathing are more effective.
C. "Atelectasis affects only those with chronic conditions such as emphysema." Atelectasis can affect anyone, especially postoperatively due to shallow breathing and reduced lung expansion. It is not exclusive to chronic conditions.
D. "It is important to do breathing exercises every hour to prevent atelectasis." Frequent deep breathing exercises, coughing, and incentive spirometry are essential for preventing atelectasis, especially after surgery.
Correct Answer is D
Explanation
- Sensory perception: Slightly limited (score of 3)
- Moisture: Rarely moist (score of 4)
- Activity: Walks occasionally (score of 3)
- Mobility: Slightly limited (score of 3)
- Nutrition: Excellent intake (score of 4)
- Friction and shear: No apparent problem (score of 3)
Adding these scores together: 3 + 4 + 3 + 3 + 4 + 3 = 20
Therefore, the nurse should document a score of 20 for this patient.
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