When caring for a client with a cervical spinal cord injury, which intervention is the most important for the nurse to implement?

Assess the extremity reflexes.

Logroll to change positions.

Immobilize the head in anatomical alignment.

Obtain hourly neurological assessments.

Answer and Explanation

The Correct Answer is C

Choice A reason: Assessing the extremity reflexes is important for evaluating neurological function but is not the immediate priority.

Choice B reason: Logrolling to change positions is a technique used to maintain spinal alignment, but it is not the first intervention to ensure immediate safety.

Choice C reason:

The correct answer is c) because immobilizing the head in anatomical alignment is crucial to prevent further injury to the spinal cord. Proper immobilization helps stabilize the cervical spine and protects the spinal cord from additional damage.

Choice D reason: Obtaining hourly neurological assessments is important for monitoring the client's condition but comes after ensuring the cervical spine is properly immobilized.

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Correct Answer is D

Explanation

Choice A reason: Antibiotics are not effective against fungal infections like athlete's foot.

Choice B reason: Continuing the use of antibiotics will not help with a fungal infection.

Choice C reason: Applying a thin layer of ointment is not relevant for treating athlete's foot with antibiotics.

Choice D reason:

The correct answer is d) because athlete's foot is a fungal infection, and proper foot hygiene, including keeping the feet dry and wearing clean socks, is essential for treatment.

A. Hypotension and venous pooling in the extremities. B. Pain and a burning sensation upon urination and hematuria. C. Profuse diaphoresis and severe, pounding headache. D. Reports of chest pain and shortness of breath.

Correct Answer is C

Explanation

Choice A reason: Hypotension and venous pooling in the extremities are not typical of autonomic dysreflexia. Autonomic dysreflexia usually results in hypertension due to an exaggerated autonomic response to a stimulus such as a full bladder. This condition is characterized by severe, uncontrolled hypertension rather than hypotension.

Choice B reason: While pain and a burning sensation upon urination and hematuria can be related to a urinary tract infection or bladder issue, they are not specific to autonomic dysreflexia. Autonomic dysreflexia presents with symptoms that result from the body's exaggerated response to the stimulus, such as severe headache and sweating.

Choice C reason:

The correct answer is c) because profuse diaphoresis (sweating) and a severe, pounding headache are hallmark signs of autonomic dysreflexia. This condition occurs in individuals with spinal cord injuries at or above the T6 level and is triggered by stimuli like a full bladder, causing a dangerous rise in blood pressure and severe autonomic responses.

Choice D reason: Reports of chest pain and shortness of breath are not typical signs of autonomic dysreflexia. While these symptoms may be concerning, they are not the primary indicators of this specific condition. The severe headache and sweating are more indicative of autonomic dysreflexia.

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When caring for a client with a cervical spinal cord injury, which intervention is the most important for the nurse to implement?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The parent of an adolescent tells the clinic nurse, "My child has athlete's foot. I have been applying triple antibiotic ointment for two days, but there has been no improvement." Which instruction should the nurse provide?

Correct Answer is D

Explanation

A client who had a C-5 spinal cord injury 2 years ago is admitted to the emergency department (ED) with the diagnosis of autonomic dysreflexia secondary to a full bladder. Which assessment finding should the nurse expect this client to exhibit?

Correct Answer is C

Explanation

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