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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A Rationale: Repositioning may be important for preventing complications, but it does not explain the pain described by the client.
Choice B Rationale: A continual inflammatory process is not typically the cause of the pain described by the client with a spinal cord injury.
Choice C Rationale: Nerve damage in the spinal cord is a common cause of neuropathic pain with these characteristics.
Choice D Rationale: Telling the client that the pain will go away in 2 weeks without further assessment or explanation is not accurate and may raise unrealistic expectations.
Correct Answer is A
Explanation
Choice A Rationale: "You sound overwhelmed, can you tell me more?" is an empathetic response that encourages the caregiver to express their feelings and concerns. It opens the door for effective communication and understanding.
Choice B Rationale: "It will take time, but lots of people do it" may be true, but it does not directly address the caregiver's emotional state or offer support.
Choice C Rationale: "What do you think will be the hardest thing to handle?" is a probing question that can help identify specific concerns, but it may not be the most appropriate initial response.
Choice D Rationale: "The entire healthcare team will manage most of the disease process" does not acknowledge the caregiver's emotions and concerns and may not provide the needed support.
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