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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A Rationale: Lethargy is not a typical manifestation of trigeminal neuralgia.
Choice B Rationale: Pain is the hallmark symptom of trigeminal neuralgia and is known to significantly affect a person's quality of life. The pain is often severe, sudden, and recurrent.
Choice C Rationale: Social withdrawal can result from the pain and discomfort associated with trigeminal neuralgia, but it is a consequence rather than a primary manifestation.
Choice D Rationale: Poor hygiene may occur as a result of the pain and discomfort associated with trigeminal neuralgia, but it is not a primary symptom of the condition.
Correct Answer is D
Explanation
Choice A Rationale: Cleansing the wound may be necessary, but the priority in this case is to assess for any retained foreign bodies, such as the nail, and potential structural damage, which can be done through an X-ray.
Choice B Rationale: The client's immunization history is not the priority when assessing and managing a wound like this.
Choice C Rationale: Dressing the wound may be necessary but should come after assessing for retained foreign bodies and potential structural damage.
Choice D Rationale: Requesting an X-ray is the priority action because it helps determine if the nail is still present and if there is any damage to deeper structures, such as bones or foreign body remnants.
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