When planning care for a client with a C3 spinal cord injury, which of the following will the nurse identify as the priority ongoing assessment?

A Urinary output

B Blood Pressure

C Counting respirations

D Bowel sounds

Answer and Explanation

The Correct Answer is C

Choice A Rationale: Urinary output is also an important assessment in clients with a C3 spinal cord injury because it helps monitor for urinary retention and potential complications but it is not a priority compared to assessing the respiratory function of this client.

Choice B Rationale: Blood pressure is important to monitor but may not be the top priority assessment in this context.

Choice C Rationale: The nurse should prioritize counting respirations for a client with a C3 spinal cord injury, as this level of injury affects the phrenic nerve that innervates the diaphragm. The client may have difficulty breathing and require mechanical ventilation.

Choice D Rationale: Bowel sounds are important but may not be the priority assessment in this case.

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Correct Answer is A

Explanation

Choice A Rationale: Lentils have one of the highest fiber contents per cup compared to the other options listed, making them a good choice to help alleviate constipation.

Choice B Rationale: Asparagus is a source of fiber but typically has lower fiber content per cup compared to lentils.

Choice CRationale: Oatmeal is known for its fiber content, but its fiber content per cup is typically lower than that of lentils.

Choice DRationale: Cabbage is a source of fiber, but its fiber content per cup is usually lower than that of lentils.

A. A Sit the client at a 90 degree angle B. B Administer 2000 liters of fluid C. C Apply compression socks D. D Maintain blood pressure exactly at 110/80

Correct Answer is A

Explanation

Choice A Rationale: Sitting the client at a 90-degree angle (upright position) helps prevent orthostatic hypotension and cardiovascular complications in clients with spinal cord injuries by improving venous return and cardiac output.

Choice B Rationale: Administering 2000 liters of fluid is an inappropriate intervention, and the volume mentioned is excessive.

Choice C Rationale: Applying compression socks may help prevent deep vein thrombosis (DVT) but does not address cardiovascular complications related to sitting position.

Choice D Rationale: Maintaining blood pressure exactly at 110/80 is not a feasible or appropriate intervention.

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