Immediately following a spinal cord injury, a patient asks about the extent of impairment that will result from the injury. The best response by the nurse is:

The extent of your injury cannot be determined until any secondary injury to the cord has resolved.

An MRI can reveal the extent of cord damage.

You will have normal function when spinal shock resolves and the reflex arc returns.

Because rehabilitation can affect the return of function, it will be years before impairment can be determined.

Answer and Explanation

The Correct Answer is A

Choice A reason:

The extent of impairment following a spinal cord injury cannot be determined until any secondary injury to the cord has resolved. Secondary injury, such as inflammation and swelling, can worsen the initial damage and impact the long-term prognosis.

Choice B reason:

An MRI can reveal the extent of cord damage but does not provide a complete picture of the potential functional outcomes. The full extent of impairment cannot be determined solely by imaging.

Choice C reason:

Stating that the patient will have normal function when spinal shock resolves and the reflex arc returns is misleading and overly optimistic. Not all patients will regain normal function after a spinal cord injury, and outcomes vary.

Choice D reason:

While rehabilitation plays a crucial role in recovery, stating that it will be years before impairment can be determined is not entirely accurate. Functional outcomes can often be assessed sooner as the initial recovery phase progresses.

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Correct Answer is C

Explanation

Choice A reason:

The application of PEEP does not inherently increase the need for FiO2 (fraction of inspired oxygen) administration. PEEP helps improve oxygenation, potentially reducing the need for higher FiO2 levels.

Choice B reason:

While PEEP can contribute to better lung inflation by keeping the alveoli open, this is a secondary effect. The primary goal of PEEP is to prevent alveolar collapse at the end of expiration.

Choice C reason:

PEEP prevents alveolar collapse during expiration, which is its primary therapeutic effect. By maintaining a certain level of pressure in the lungs at the end of expiration, PEEP ensures that the alveoli remain open, improving gas exchange and oxygenation.

Choice D reason:

Although PEEP can help reduce the risk of atelectasis (collapse of part or all of a lung), it does not directly prevent barotrauma. Barotrauma is related to high airway pressures, and careful monitoring of ventilator settings is necessary to avoid it.

A. Respiratory rate is 26. B. +1 pedal pulses. C. Body temperature is 36.8°C (rectal). D. Urine output is greater than 40 cc/hr.

Correct Answer is D

Explanation

Choice A reason:

While an increased respiratory rate can indicate a compensatory response to shock, it does not directly measure tissue perfusion. It suggests the body is attempting to improve oxygen delivery, but it is not a definitive indicator of adequate tissue perfusion.

Choice B reason:

+1 pedal pulses can indicate decreased perfusion to the extremities, but they do not provide comprehensive information about overall tissue perfusion. Peripheral pulses can be weak in shock due to vasoconstriction and poor circulation, but they are not the most reliable indicator of tissue perfusion.

Choice C reason:

Body temperature is not a direct measure of tissue perfusion. While it is important to monitor, changes in temperature can result from various factors and do not specifically reflect the adequacy of tissue perfusion.

Choice D reason:

Urine output greater than 40 cc/hr is a key indicator of adequate tissue perfusion. The kidneys are highly sensitive to changes in perfusion, and adequate urine output suggests that the kidneys are receiving sufficient blood flow to filter and excrete waste products. Monitoring urine output is a standard practice in assessing tissue perfusion and overall fluid balance in shock patients.

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Immediately following a spinal cord injury, a patient asks about the extent of impairment that will result from the injury. The best response by the nurse is:

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Naxlex Comprehensive Predictor Exams

When planning care for a patient on a mechanical ventilator, the nurse understands that the application of positive end-expiratory pressure (PEEP) to the ventilator settings has which therapeutic effect?

Correct Answer is C

Explanation

Which assessment of a patient in shock would give the nurse the most valuable information to determine there is adequate tissue perfusion?

Correct Answer is D

Explanation

As a community health nurse, you are planning to conduct an education session on prevention strategies for spinal cord injuries. Which population would benefit most from this education?

A client is on mechanical ventilation and the client's spouse wonders why famotidine is needed since the client "only has lung problems." What response by the nurse is best?

A charge nurse is reviewing the status of patients in the critical care unit. Which patient should the charge nurse notify the organ procurement team to evaluate for possible organ donation?

The nurse is managing a donor patient six hours prior to the scheduled harvesting of the patient's organs. Which assessment finding requires immediate action by the nurse?

A patient is admitted to the emergency department with a spinal cord injury at the level of T2 following a traumatic fall from a roof. Which finding is of most concern to the nurse?

A nurse is caring for a client in acute respiratory failure who is receiving mechanical ventilation. Which of the following assessments is the best method to determine the effectiveness of the current treatments?

Immediately following a spinal cord injury, a patient asks about the extent of impairment that will result from the injury. The best response by the nurse is:

The nurse is caring for a mechanically ventilated spinal cord injury patient in the ICU. To avoid the complication of autonomic dysreflexia, the nurse plans to implement the following orders: