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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Altered mental status, such as confusion, restlessness, or lethargy, is often the earliest sign of increasing ICP as it reflects brain tissue compression.
B. Tachycardia and hypotension are not primary indicators of elevated ICP.
C. Fixed and dilated pupils indicate severe and often irreversible ICP increase, occurring later in the progression.
D. Widening pulse pressure is a later sign of increased ICP, following changes in mental status.
Correct Answer is D
Explanation
A. Anesthetic eye drops can help with pain, but irrigation is the priority to prevent further damage.
B. A visual acuity exam is part of the assessment but should be performed after initial irrigation to prevent further damage.
C. Determining the pH of the chemical splash can guide further treatment but is secondary to immediate irrigation to dilute and remove the chemical.
D. Irrigating both eyes with normal saline is the priority action to dilute and flush out the chemical, reducing the risk of further injury.
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