Which of the following diagnostic tests is commonly used to assess heart failure?

Choice A Reason:
Maintaining the cervical collar in place is crucial for a client with a spinal cord injury at the level of C3-4. This action prevents further damage to the spinal cord by immobilizing the neck and maintaining proper alignment. Any movement could exacerbate the injury, potentially leading to more severe neurological deficits or even paralysis.

Choice B Reason:
Asking the client if they remember any events around the time of the injury is not the priority in this situation. While obtaining a history is important, it should not take precedence over stabilizing the spinal cord to prevent further injury. The primary focus should be on ensuring the client's safety and preventing additional harm.

Choice C Reason:
Explaining to the client that they will never be able to walk again is inappropriate and premature. The prognosis for spinal cord injuries can vary widely, and it is essential to provide accurate information based on a thorough assessment and consultation with specialists. Additionally, delivering such news requires sensitivity and should be done in a supportive manner.

Choice D Reason:
Notifying the client's parents that they are in the ED is important for family communication and support. However, it is not the immediate priority. The primary focus should be on stabilizing the client's condition and preventing further injury. Once the client is stabilized, the nurse can then inform the family.

Choice A Reason:
Suctioning the nose is not the first action to take. Suctioning can increase intracranial pressure and potentially cause further injury. It is important to first determine the nature of the drainage before taking any invasive actions.

Choice B Reason:
Notifying the physician is important, but it should be done after confirming the nature of the drainage. Testing the fluid for glucose can help determine if it is cerebrospinal fluid (CSF), which would indicate a serious complication requiring immediate medical attention.

Choice C Reason:
Testing the drainage for glucose is the correct first action. CSF contains glucose, so a positive test would confirm that the clear fluid is CSF. This is a critical step in diagnosing a CSF leak, which can occur with basal skull fractures and requires prompt intervention to prevent infection and other complications.

Choice D Reason:
Asking the client to blow their nose is contraindicated. Blowing the nose can increase intracranial pressure and exacerbate a CSF leak. It is important to avoid any actions that could worsen the condition until the nature of the drainage is confirmed.