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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. The client can follow simple motor commands: A GCS score of 5 for the best motor response indicates that the client can localize pain but cannot follow simple motor commands. A score of 6 or higher is required to demonstrate following commands.
B. The client is unable to make vocal sound: A GCS score of 5 for the best verbal response indicates incomprehensible sounds or no verbal response. It does not specifically indicate the client's ability to vocalize or make sounds.
C. The client opens his eyes when spoken to: A GCS score of 3 for eye opening indicates no eye opening even to painful stimuli. It does not suggest that the client opens his eyes when spoken to.
D. The client is unconscious: A GCS score of 3 for eye opening, 5 for best verbal response, and 5 for best motor response indicates severe neurological impairment, with the client being unresponsive to stimuli and unable to follow commands. Therefore, the appropriate conclusion is that the client is unconscious.
Correct Answer is ["B","D"]
Explanation
A. Furnish restraints at the bedside: Restraints are not indicated for clients with seizure disorders. In fact, restraints can increase the risk of injury during a seizure and should be avoided.
B. Keep an oxygen setup at the bedside: Oxygen may be necessary to support the client's respiratory function during and after a seizure. Having an oxygen setup readily available can ensure prompt administration if needed.
C. Place the bed in the lowest position: Lowering the bed can help prevent injury if the client
falls out of bed during a seizure. However, it is not always feasible or necessary to lower the bed to the lowest position, especially if the client has mobility limitations or other considerations.
D. Provide a suction setup at the bedside: Suctioning may be necessary to clear the airway and prevent aspiration if the client experiences excessive oral secretions or vomiting during or after a seizure.
E. Elevate the side rails near the head when the client is in bed: Elevating the side rails near the head can help prevent injury if the client thrashes or moves unpredictably during a seizure. However, it is essential to ensure that the client's head and neck remain adequately supported and that the side rails do not restrict access to the client during a seizure.
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