When caring for a client with a cervical spinal cord injury, which intervention is the most important for the nurse to implement?

Assess the extremity reflexes.

Logroll to change positions.

Immobilize the head in anatomical alignment.

Obtain hourly neurological assessments.

Answer and Explanation

The Correct Answer is C

Choice A reason: Assessing the extremity reflexes is important for evaluating neurological function but is not the immediate priority.

Choice B reason: Logrolling to change positions is a technique used to maintain spinal alignment, but it is not the first intervention to ensure immediate safety.

Choice C reason:

The correct answer is c) because immobilizing the head in anatomical alignment is crucial to prevent further injury to the spinal cord. Proper immobilization helps stabilize the cervical spine and protects the spinal cord from additional damage.

Choice D reason: Obtaining hourly neurological assessments is important for monitoring the client's condition but comes after ensuring the cervical spine is properly immobilized.

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Correct Answer is B

Explanation

Choice A reason: Avoiding driving is important but not the most critical instruction.

Choice B reason:

The correct answer is b) because drinking plenty of water helps flush the bladder, reduce the risk of infection, and prevent blood clots.

Choice C reason: Eliminating spicy foods may help with overall comfort but is not as important as maintaining proper hydration.

Choice D reason: Clamping the catheter during a shower is not necessary and could cause complications.

A. Keep room temperature cool. B. Determine the client's food preferences. C. Maintain a patent intravenous site. D. Teach the client relaxation techniques.

Correct Answer is C

Explanation

Choice A reason: Keeping the room temperature cool may help with comfort but is not the immediate priority.

Choice B reason: Determining the client's food preferences is important for nutritional management but is not the first action to take.

Choice C reason:

The correct answer is c) because maintaining a patent intravenous site is crucial for administering fluids and medications to address severe dehydration and malnutrition.

Choice D reason: Teaching relaxation techniques can help with restlessness but is not the most immediate concern.

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When caring for a client with a cervical spinal cord injury, which intervention is the most important for the nurse to implement?

Nursing Test Bank

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