A nurse is caring for a client who was brought to the emergency department (ED) by EMS after diving into a lake and losing consciousness. The client was intubated in the field by the paramedics. A CT of the head and neck revealed a spinal cord injury at the level of C3-4. What is the priority nursing action?
Maintain the cervical collar in place.
Ask the client if they remember any events around the time of the injury.
Explain to the client that they will never be able to walk again.
Notify the client's parents that they are in the ED.
The Correct Answer is A
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A: Vitamin K
Vitamin K is essential for the synthesis of clotting factors and is often used to treat bleeding disorders caused by vitamin K deficiency or to reverse the effects of anticoagulants like warfarin. However, in the context of disseminated intravascular coagulation (DIC), the primary issue is not a deficiency of clotting factors but rather an overactivation of the clotting cascade leading to both clot formation and bleeding. Therefore, while vitamin K can be beneficial in certain bleeding disorders, it is not the primary treatment for DIC.
Choice B: Statin
Statins are medications used to lower cholesterol levels and reduce the risk of cardiovascular disease. They work by inhibiting the enzyme HMG-CoA reductase, which plays a crucial role in cholesterol synthesis. Statins are not used in the management of DIC as they do not address the underlying pathophysiology of the condition, which involves widespread clotting and subsequent bleeding.
Choice C: Heparin
Heparin is an anticoagulant that helps prevent the formation of new clots and the extension of existing clots. In the management of DIC, heparin can be used to interrupt the clotting process and prevent further consumption of clotting factors. This can help stabilize the patient and reduce the risk of severe bleeding. Heparin is particularly useful in cases where thrombosis is predominant. It is important to monitor the patient closely to balance the risk of bleeding with the benefits of anticoagulation.
Choice D: Metformin
Metformin is an oral hypoglycemic agent used to manage type 2 diabetes by improving insulin sensitivity and reducing glucose production in the liver. It has no role in the treatment of DIC, as it does not affect the coagulation pathways or the underlying causes of DIC.
Correct Answer is D
Explanation
Choice A Reason:
Monitoring the client's respiratory status and oxygen saturation is important but not the primary purpose of a hemodynamic monitoring system. Hemodynamic monitoring focuses on the cardiovascular system, including parameters like cardiac output, stroke volume, and systemic vascular resistance.
Choice B Reason:
Evaluating the client's renal function and electrolyte balance is crucial in overall patient care but is not the main focus of hemodynamic monitoring. Hemodynamic monitoring systems are designed to assess cardiovascular function rather than renal function.
Choice C Reason:
Monitoring the client's neurological status and intracranial pressure is essential in certain clinical situations, such as traumatic brain injury. However, this is not the primary purpose of hemodynamic monitoring, which is centered on cardiovascular assessment.
Choice D Reason:
The primary purpose of a hemodynamic monitoring system is to measure and assess the client's cardiovascular status and function. This includes monitoring parameters such as blood pressure, cardiac output, and tissue perfusion to ensure adequate organ perfusion and guide treatment decisions.
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