A patient has been admitted to the intensive care unit (ICU) with a spinal cord injury following a motor vehicle accident.
Who should be contacted to manage the progression of the patient’s care?

Supervisor of the neurology unit.

Nurse in charge of risk management.

Nurse case manager.

Adult nurse practitioner.

Answer and Explanation

The Correct Answer is C

Choice A rationale

While the supervisor of the neurology unit may have expertise in neurology, they are not typically responsible for coordinating the progression of a patient’s care following a spinal cord injury.

Choice B rationale

The nurse in charge of risk management is typically responsible for identifying and evaluating risks in the healthcare setting. They are not typically involved in the direct management of a patient’s care.

Choice C rationale

The nurse case manager is specifically trained to coordinate and manage the care of patients with complex conditions, including spinal cord injuries. They work with the patient, family, and healthcare team to develop a comprehensive care plan.

Choice D rationale

While an adult nurse practitioner can provide a high level of care, they are not typically responsible for managing the progression of a patient’s care following a spinal cord injury.

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Correct Answer is {"A":{"answers":"A"},"B":{"answers":"B"},"C":{"answers":"A"}}

Explanation

Based on the provided information, here are the interventions the nurse should perform:

Check capillary refill on bilateral upper extremities.- Indicated: This is important to assess the client’s circulation, especially given the coolness of the left arm and the fracture in the left shoulder.
Administer ondansetron 4 mg IV.- Contraindicated: There is no prescription for ondansetron and no indication of nausea or vomiting from the client.
Inspect the bandage for drainage.- Indicated: Given the client’s recent surgery and the presence of swelling and bruising, it’s important to monitor for any signs of infection or complications.

A. Auscultate an area six inches below the umbilicus. B. Observe the appearance of the patient’s urine. C. Palpate the area above the pubic symphysis. D. Measure the girth of the patient’s lower abdomen.

Correct Answer is C

Explanation

Choice A rationale

Auscultating an area six inches below the umbilicus would not provide the most useful data when assessing for possible urinary retention. Auscultation is typically used to assess bowel sounds and not typically used in the assessment of urinary retention.

Choice B rationale

Observing the appearance of the patient’s urine can provide some information about the patient’s hydration status and kidney function, but it would not be the most useful technique for assessing urinary retention.

Choice C rationale

Palpating the area above the pubic symphysis can provide useful data when assessing for possible urinary retention. If the bladder is distended due to urinary retention, it may be palpable in this area.

Choice D rationale

Measuring the girth of the patient’s lower abdomen is not typically used as a method to assess for urinary retention. While an increase in abdominal girth can occur with urinary retention, it is not the most direct or reliable method for assessment.

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A patient has been admitted to the intensive care unit (ICU) with a spinal cord injury following a motor vehicle accident.Who should be contacted to manage the progression of the patient’s care?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Exhibits Click to indicate which interventions the nurse should perform to care for this client. Each row must have one response indicated.

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"B"},"C":{"answers":"A"}}

Explanation

Which assessment technique would provide the most useful data when the nurse is concerned about possible urinary retention?

Correct Answer is C

Explanation

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A patient has been admitted to the intensive care unit (ICU) with a spinal cord injury following a motor vehicle accident.
Who should be contacted to manage the progression of the patient’s care?