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 D
Explanation
Choice A Rationale: Loosening all of the connections on the vest to assess the skin is not the first priority and may compromise the stability of the halo brace.
Choice B Rationale: Asking about the client's ability to perform range of motion to legs is important but may not be the first priority.
Choice C Rationale: Asking how the client is able to reposition self in bed is important but may not be the first priority.
Choice D Rationale: Assessing the pin sites is the first priority in caring for a client with a halo brace, as complications related to pin site infections or issues can have significant consequences. Pin site care and assessment are crucial to prevent infections and complications.
Correct Answer is ["A","B","C","D"]
Explanation
Choice A Rationale: Understanding the expected physiological changes of Alzheimer's disease can help the caregiver better cope with the client's behaviors and needs.
Choice B Rationale: Teaching actions to reduce stress is important for both the caregiver and the client, as stress can exacerbate behavioral symptoms in Alzheimer's disease.
Choice C Rationale: Referring to available community resources can provide valuable support and assistance to both the caregiver and the client.
Choice D Rationale: Identifying a social support system is essential for the caregiver to have emotional and practical support while caring for a client with Alzheimer's disease.
Choice E Rationale: While medication administration is important, it may not be the primary focus of coping strategies for the caregiver.
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