When planning care for a client with a C3 spinal cord injury, which of the following will the nurse identify as the priority ongoing assessment?
A Urinary output
B Blood Pressure
C Counting respirations
D Bowel sounds
The Correct Answer is C
Choice A Rationale: Urinary output is also an important assessment in clients with a C3 spinal cord injury because it helps monitor for urinary retention and potential complications but it is not a priority compared to assessing the respiratory function of this client.
Choice B Rationale: Blood pressure is important to monitor but may not be the top priority assessment in this context.
Choice C Rationale: The nurse should prioritize counting respirations for a client with a C3 spinal cord injury, as this level of injury affects the phrenic nerve that innervates the diaphragm. The client may have difficulty breathing and require mechanical ventilation.
Choice D Rationale: Bowel sounds are important but may not be the priority assessment in this case.
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Correct Answer is B
Explanation
Choice A Rationale: Notifying the physician may be necessary if troubleshooting the issue does not resolve the problem, but it is not the initial step.
Choice B Rationale: The nurse should first check the tubing of the indwelling urinary catheter for any kinks, twists, or obstructions that might prevent the urine flow. This is a simple and non-invasive intervention that can resolve the problem quickly and easily.
Choice C Rationale: Removing the indwelling catheter is not advisable without proper assessment and intervention, as it can lead to complications.
Choice D Rationale: Replacing the indwelling catheter is not the first step and should only be done if the problem cannot be resolved through assessment and interventions.
Correct Answer is ["A","B","D"]
Explanation
Choice A Rationale: A weakened gag reflex is a potential complication of a cervical spinal cord injury and can lead to difficulties in swallowing and increased risk of aspiration.
Choice B Rationale: Hyperthermia can occur as a result of autonomic dysfunction associated with spinal cord injuries, especially when the injury is at a high cervical level.
Choice C Rationale: Absence of bowel sounds is not typically associated with cervical spinal cord injuries but may be seen in lower spinal cord injuries.
Choice D Rationale: Hypotension is a potential complication due to impaired autonomic regulation in cervical spinal cord injuries.
Choice E Rationale: Polyuria is not typically associated with cervical spinal cord injuries but may occur in cases of lower spinal cord injuries affecting bladder function.
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