A nurse is caring for a client who has a C4 spinal cord injury. Which of the following should the nurse recognize the client as being at the greatest risk for?
Respiratory compromise.
Stress ulcer.
Paralytic ileus.
Spinal shock.
The Correct Answer is A
Choice A reason: Respiratory compromise is the greatest risk for a client with a C4 spinal cord injury. The C4 spinal level is critical for the function of the diaphragm, which is the main muscle responsible for breathing. Injury at this level can impair diaphragmatic function, leading to difficulty in breathing or even respiratory failure. Immediate and continuous monitoring of respiratory status is essential for these patients to ensure adequate ventilation and oxygenation.
Choice B reason: Stress ulcers can develop in patients with spinal cord injuries due to the stress response and immobility. However, they are not the highest immediate risk compared to respiratory compromise, which can be life-threatening if not promptly addressed.
Choice C reason: Paralytic ileus, a condition where the intestines stop moving, can occur in spinal cord injury patients due to disruption of the nervous system control of the gut. While it is a significant concern, it is not as immediately life-threatening as respiratory compromise.
Choice D reason: Spinal shock is a condition that can occur after a spinal cord injury, leading to temporary loss of reflexes below the level of the injury. While it is an important condition to recognize and manage, the most urgent risk for a patient with a C4 injury is respiratory compromise due to the potential impact on breathing.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Vasopressin (Desmopressin) is not primarily used to decrease blood pressure. It is an antidiuretic hormone that helps manage diabetes insipidus by reducing urine output. While vasopressin can have vasoconstrictive effects, its primary role in this context is to control urine production, not blood pressure.
Choice B reason: The primary therapeutic outcome of vasopressin (Desmopressin) in a patient with diabetes insipidus is to decrease urine output. Diabetes insipidus leads to excessive urine production and dehydration. Vasopressin acts on the kidneys to increase water reabsorption, thereby reducing urine volume and helping to maintain fluid balance.
Choice C reason: Level of consciousness is not a direct therapeutic outcome of vasopressin (Desmopressin). While managing fluid balance can indirectly affect a patient's overall condition and well-being, vasopressin specifically targets the kidneys to reduce urine output and does not have a direct impact on consciousness levels.
Choice D reason: Specific gravity refers to the concentration of solutes in the urine. While vasopressin can affect the specific gravity by concentrating the urine and reducing volume, the primary therapeutic goal is to manage urine output in patients with diabetes insipidus. The focus is on reducing the excessive urine production rather than altering specific gravity.
Correct Answer is D
Explanation
Choice A reason: Suctioning the patient immediately is not the appropriate intervention in this context. Suctioning can be necessary if the patient has secretions obstructing the airway, but it does not address the issues of bradycardia (low heart rate) and hypotension (low blood pressure) which are critical in a spinal cord injury.
Choice B reason: Administering normal saline (NS) at 25 cc/hr is not sufficient to address the patient's hypotension. In a patient with a spinal cord injury at the T5 level, hypotension is likely due to neurogenic shock, and more aggressive fluid resuscitation or pharmacological support is needed.
Choice C reason: Raising the head of the bed is not appropriate for managing the patient's condition. In fact, keeping the head elevated can worsen hypotension by reducing venous return to the heart. The focus should be on stabilizing blood pressure and heart rate.
Choice D reason: The correct intervention is starting a dopamine IV drip. Dopamine is a vasopressor that helps increase blood pressure and heart rate, which is crucial in managing neurogenic shock. By administering dopamine, the nurse can help stabilize the patient's cardiovascular status and improve perfusion to vital organs.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.