The Emergency Department nurse is expecting a patient with a spinal cord transection at C1. Which of the following assessments take priority upon the patient's arrival? (SELECT ALL THAT APPLY)

Blood pressure

Bladder function

Heart rate

Reflexes

Respirations

Answer and Explanation

Correct Answer : A,C,E

A. Blood pressure monitoring is essential, as spinal cord injuries at high levels can cause disruptions in autonomic regulation, leading to significant blood pressure fluctuations.

B. Bladder function is impacted by spinal cord injuries; however, it is not the initial priority in an emergency setting when life-threatening complications must be managed first.

C. Heart rate is critical as high spinal cord injuries can impact cardiac function by affecting autonomic control, potentially leading to bradycardia.

D. Reflexes are often assessed in cases of spinal injury, but they are not the immediate priority when stabilizing the patient upon arrival.

E. Respirations are a priority, as a C1 spinal cord injury can compromise respiratory function, necessitating immediate assessment to ensure adequate oxygenation and airway management.

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Correct Answer is A

Explanation

A. Neurogenic shock occurs in spinal cord injuries above T6 and is characterized by hypotension, bradycardia, and loss of sympathetic tone below the level of injury. This condition results from disruption of autonomic pathways.

B. Brain herniation typically involves increased intracranial pressure and different neurological symptoms.

C. Spinal shock involves temporary loss of reflexes and sensation but does not specifically cause bradycardia or hypotension.

D. Autonomic dysreflexia involves sudden high blood pressure and is usually triggered by noxious stimuli, occurring after the acute phase of SCI.

A. accident injured the patient's lungs. B. patient has a history of smoking. C. nerves that control the lung function have been injured. D. patient is unable to breathe because he is unconscious.

Correct Answer is C

Explanation

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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The Emergency Department nurse is expecting a patient with a spinal cord transection at C1. Which of the following assessments take priority upon the patient's arrival? (SELECT ALL THAT APPLY)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Correct Answer is C

Explanation

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