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: 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.
Correct Answer is A
Explanation
Choice A Rationale: The purpose of a halo fixation device is to immobilize the cervical spine and prevent movement, which is crucial for healing and preventing further spinal cord injury.
Choice B Rationale: A halo fixation device does not allow for neck movement during the healing process.
Choice C Rationale: Applying talcum powder under the vest may increase the risk of skin irritation or infection.
Choice D Rationale: Turning the screws on the device should only be done by qualified healthcare professionals, not by the family.
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