A patient presents to the emergency department with a cervical spinal cord injury immediately after a motor vehicle crash. What should the nurse explain to the family as the reason for the patient being placed on mechanical ventilation? The:

accident injured the patient's lungs.

patient has a history of smoking.

nerves that control the lung function have been injured.

patient is unable to breathe because he is unconscious.

Answer and Explanation

The Correct Answer is C

A. While lung injury could occur in traumatic situations, it is not the primary reason for mechanical ventilation in the context of a spinal cord injury.

B. A history of smoking may affect lung health but does not directly justify the immediate need for mechanical ventilation following a spinal cord injury.

C. The nerves that control lung function may be injured in a cervical spinal cord injury, particularly at higher levels like C3-C5, leading to respiratory muscle paralysis and necessitating mechanical ventilation to support breathing.

D. While unconsciousness may complicate breathing, the primary concern is the loss of function in the spinal cord nerves controlling respiration.

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Correct Answer is C

Explanation

A. Suctioning can increase ICP due to the Valsalva response and should only be done if absolutely necessary.

B. Documenting without intervention could lead to worsening of the patient's condition.

C. Notifying the physician and raising the head of the bed helps to reduce ICP by promoting venous drainage. An ICP of 30 mmHg is critically high, requiring immediate intervention to prevent further damage.

D. Lowering the head of the bed can increase ICP further; head elevation is recommended to improve cerebral drainage.

A. Padded tongue blades to prevent injury in the event of seizure B. Soft wrist restraints to prevent injury C. Ambu bag and oxygen connection for respiratory distress D. Wrenches for emergency removal of traction equipment E. Oral suction tube (Yankaur) for secretion removal

Correct Answer is ["C","D","E"]

Explanation

A. Padded tongue blades are not appropriate for seizure management and are not necessary in this context.

B. Soft wrist restraints are not required in this scenario unless otherwise indicated.

C. An Ambu bag and oxygen are crucial for respiratory support, especially if the patient has compromised breathing due to spinal cord injury.

D. Wrenches should be readily available to quickly remove halo traction in case of an emergency, such as if the patient's airway needs to be accessed.

E. An oral suction tube (Yankauer) is important for managing oral secretions, which can be challenging for patients with limited mobility.

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A patient presents to the emergency department with a cervical spinal cord injury immediately after a motor vehicle crash. What should the nurse explain to the family as the reason for the patient being placed on mechanical ventilation? The:

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Naxlex Comprehensive Predictor Exams

The nurse is caring for a patient in the ICU with a diagnosis of acute closed head injury whose intracranial pressure (ICP) is 30mmHg. What is the priority action by the nurse?

Correct Answer is C

Explanation

The nurse is caring for a patient who suffered a spinal cord injury (SCI) who has had halo traction placed for spinal immobilization. What emergency equipment should the nurse have at the bedside? (SELECT ALL THAT APPLY)

Correct Answer is ["C","D","E"]

Explanation

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