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 B
Explanation
A. Scheduled voiding is less effective in patients with a flaccid bladder because there is no voluntary control of bladder function.
B. Intermittent catheterization is the preferred management technique for a flaccid or atonic bladder, allowing the bladder to empty at regular intervals and reducing the risk of infection associated with continuous catheters.
C. An indwelling catheter is usually avoided for long-term use due to a higher risk of infection.
D. An external catheter is generally not effective for flaccid or atonic bladder management in spinal cord injuries as it doesn’t actively empty the bladder.
Correct Answer is D
Explanation
A. Abnormal sensory sensations such as tingling may be associated with the aura phase of a seizure but are not typically observed postictally.
B. Yellowing of the skin is usually indicative of jaundice, unrelated to seizure activity or the postictal state.
C. Itching of the eyes is unrelated to seizure activity and would not typically be documented in the context of postictal observations.
D. The postictal state is characterized by drowsiness, confusion, and other altered mental statuses that follow a seizure. This period can vary in duration depending on the patient and seizure type.
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