The nurse is caring for a patient who sustained a spinal cord injury (SCI) at T1. The alarm on the monitor sounds because the patient's blood pressure is 86/50 and the heart rate is 44. The nurse's priority action would be to:

assess the patient's neurological status and repeat vital signs

ask the patient care tech to check on the patient.

place the client in reverse Trendelenburg position.

administer intravenous (tv) fluids to increase cardiac output.

Answer and Explanation

The Correct Answer is A

A) Assess the patient's neurological status and repeat vital signs:
In patients with a spinal cord injury (SCI) at T1, autonomic dysreflexia or neurogenic shock can lead to unstable vital signs, including hypotension and bradycardia. The most immediate concern in this scenario is to determine if the patient is experiencing neurogenic shock, which can result from the loss of sympathetic nervous system function below the level of the injury. By assessing the patient’s neurological status (such as checking for changes in motor function, sensation, or level of consciousness) and repeating vital signs, the nurse can gather the necessary data to make informed decisions about further interventions.

B) Ask the patient care tech to check on the patient:
While the patient care tech can assist with tasks, this is not the priority action. The nurse must immediately assess the patient's condition, particularly given the vital sign changes and the potential for a life-threatening situation like neurogenic shock. The nurse's clinical judgment and expertise are required to evaluate the situation appropriately.

C) Place the client in reverse Trendelenburg position:
Placing the patient in reverse Trendelenburg may help with hypotension in certain situations, but it is not the priority intervention for someone with a spinal cord injury at T1. In cases of neurogenic shock or autonomic dysreflexia, positioning alone will not correct the underlying issue.

D) Administer intravenous (IV) fluids to increase cardiac output:
While IV fluids may be necessary to treat hypotension in some situations, the nurse must first assess the patient’s neurological status and repeat vital signs to determine the cause of the hypotension and bradycardia. Administering IV fluids without understanding the underlying cause could be inappropriate or even harmful, particularly if the low blood pressure is related to neurogenic shock, which requires careful management.

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Correct Answer is D

Explanation

A) Measure heart chamber pressures to assess for heart failure:
Measuring heart chamber pressures is an important diagnostic tool in assessing heart failure, but it is not the primary goal in the case of a STEMI (ST-Elevation Myocardial Infarction). In STEMI, the primary goal is to identify and treat the blockage in the coronary arteries that is causing the heart attack.

B) Determine cardiac output during the procedure:
Cardiac output is a useful measurement for assessing heart function, but it is not the main focus during the treatment of STEMI. While monitoring cardiac output may be part of the overall care, the urgent priority in STEMI management is to restore blood flow to the affected myocardial tissue as quickly as possible to minimize damage, not to measure cardiac output.

C) Evaluate the extent of the occlusion of the coronary arteries involved:
While evaluating the extent of coronary artery occlusion is part of the process during a cardiac catheterization, the immediate priority for a patient with STEMI is to treat the blockage, not just evaluate it. While the angiogram will reveal the blockage, the treatment goal is to restore perfusion to the affected area of the heart through procedures such as balloon angioplasty or stent placement.

D) Prevent extensive myocardial damage:
This is the correct answer. The main goal of treatment for STEMI is to prevent extensive myocardial damage. In a STEMI, the coronary artery is blocked, depriving the heart muscle of oxygen, which can cause significant damage or death of the myocardial tissue. The most effective way to limit the extent of damage is to restore blood flow as quickly as possible, often through emergent procedures like percutaneous coronary intervention (PCI) or fibrinolytic therapy.

A. Glascow Coma Scale B. NIH Stroke Scale C. Romberg Test D. Mini Mental Status Exam

Correct Answer is A

Explanation

A) Glasgow Coma Scale:
The Glasgow Coma Scale (GCS) is a standardized neurological assessment tool used to assess a patient's level of consciousness based on three criteria: eye opening, verbal response, and motor response. Each of these categories is scored, and the total score helps to determine the depth of the patient's consciousness. The GCS is commonly used to monitor changes in a patient's neurological status, especially after trauma, stroke, or other conditions that may impair brain function.

B) NIH Stroke Scale:
The NIH Stroke Scale (NIHSS) is used to assess the severity of stroke symptoms and includes measures such as facial droop, arm and leg motor function, speech, and language abilities. It is used specifically to evaluate stroke symptoms and is not designed for the rapid assessment of general consciousness like the Glasgow Coma Scale.

C) Romberg Test:
The Romberg Test is a test of balance that is performed by having the patient stand with their feet together, eyes closed, and observing for any swaying or loss of balance. It is used to evaluate proprioception and cerebellar function, not to assess the level of consciousness.

D) Mini Mental Status Exam:
The Mini-Mental Status Exam (MMSE) is a brief cognitive screening tool that assesses aspects of cognitive function such as orientation, attention, memory, language, and visuospatial skills. While the MMSE can provide insight into cognitive function, it does not focus on the specific assessment of consciousness level (eye opening, verbal response, motor response) as the GCS does.

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The nurse is caring for a patient who sustained a spinal cord injury (SCI) at T1. The alarm on the monitor sounds because the patient's blood pressure is 86/50 and the heart rate is 44. The nurse's priority action would be to:

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Naxlex Comprehensive Predictor Exams

A client admitted to the Emergency Department with a suspected STEM. The nurse anticipates that this client will be immediately prepared for the cardiac catheterization laboratory as the goal of treatment is to:

Correct Answer is D

Explanation

The nurse easily and quickly assesses changes in level of consciousness (eye opening, verbal responses motor response) using which neurological exams?

Correct Answer is A

Explanation

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