Which action should the nurse recognize as the highest priority for a patient who was admitted 16 hours earlier with a C5 spinal cord injury?

Cardiac monitoring for bradycardia

Administration of low-molecular-weight heparin

Assessment of respiratory rate and effort

Application of pneumatic compression devices to legs

Answer and Explanation

The Correct Answer is C

A. Cardiac monitoring for bradycardia: While cardiac changes can occur with spinal cord injury, respiratory complications are more common and pose a greater immediate threat to the patient's well-being. Therefore, assessing respiratory status takes priority over cardiac monitoring in this situation.

B. Administration of low-molecular-weight heparin: Venous thromboembolism prophylaxis is important for patients with spinal cord injury, but it is not the highest priority within the first 16 hours of admission. Respiratory assessment is more critical for immediate patient safety.

C. Assessment of respiratory rate and effort: Respiratory complications, such as impaired breathing or respiratory failure, are common in patients with spinal cord injury, particularly at the C5 level, which affects the diaphragm and intercostal muscles. Early detection of respiratory distress is crucial for timely intervention to prevent respiratory compromise.

D. Application of pneumatic compression devices to legs: Pneumatic compression devices are used for preventing venous thromboembolism, but they do not address the immediate priority of assessing and managing respiratory status in a patient with spinal cord injury.

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Correct Answer is C

Explanation

A. Administer naproxen: While pain management is important, naproxen may not effectively resolve the headache associated with post-lumbar puncture headache (PLPH), which is often caused by cerebrospinal fluid leakage.

B. Elevate the head of the bed to 30°: While elevating the head of the bed may provide some relief, it is not typically sufficient to resolve PLPH, which often requires more definitive interventions.

C. Check BP and call for a blood patch: PLPH is commonly treated with a blood patch, which involves injecting the patient's own blood into the epidural space to seal the puncture site and restore normal cerebrospinal fluid pressure. Checking blood pressure is important to assess for hypotension, and calling for a blood patch is the most appropriate action to address the underlying cause of the headache.

D. Darken the client's room and close the door: While creating a quiet and dim environment may help alleviate symptoms of headache, it does not address the underlying cause of PLPH and is not the most appropriate intervention in this situation.

A. Remove clothing B. Maintain cervical spine precaution C. Perform a mental status exam D. Assess for facial lacerations

Correct Answer is B

Explanation

A. Remove clothing: While removing clothing may be necessary for a thorough assessment and treatment, maintaining cervical spine precaution takes precedence to prevent potential spinal cord injury in clients with a history of trauma, such as a fall from a significant height.

B. Maintain cervical spine precaution: Maintaining cervical spine precaution by stabilizing the cervical spine and immobilizing the neck is crucial to prevent further injury to the spinal cord in clients with a history of trauma until spinal injury is ruled out or managed.

C. Perform a mental status exam: While assessing the client's mental status is important for evaluating neurological function, it is not the first priority in a client with potential spinal cord injury following a fall.

D. Assess for facial lacerations: Assessing for facial lacerations is important for identifying and managing potential facial injuries, but it is not the first priority in the primary assessment of a client with a history of trauma and potential spinal cord injury.

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Which action should the nurse recognize as the highest priority for a patient who was admitted 16 hours earlier with a C5 spinal cord injury?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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