Which action should the nurse recognize as the highest priority for a patient who was admitted 16 hours earlier with a C5 spinal cord injury?

Cardiac monitoring for bradycardia

Administration of low-molecular-weight heparin

Assessment of respiratory rate and effort

Application of pneumatic compression devices to legs

Answer and Explanation

The Correct Answer is C

A. Cardiac monitoring for bradycardia: While cardiac changes can occur with spinal cord injury, respiratory complications are more common and pose a greater immediate threat to the patient's well-being. Therefore, assessing respiratory status takes priority over cardiac monitoring in this situation.

B. Administration of low-molecular-weight heparin: Venous thromboembolism prophylaxis is important for patients with spinal cord injury, but it is not the highest priority within the first 16 hours of admission. Respiratory assessment is more critical for immediate patient safety.

C. Assessment of respiratory rate and effort: Respiratory complications, such as impaired breathing or respiratory failure, are common in patients with spinal cord injury, particularly at the C5 level, which affects the diaphragm and intercostal muscles. Early detection of respiratory distress is crucial for timely intervention to prevent respiratory compromise.

D. Application of pneumatic compression devices to legs: Pneumatic compression devices are used for preventing venous thromboembolism, but they do not address the immediate priority of assessing and managing respiratory status in a patient with spinal cord injury.

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Correct Answer is D

Explanation

A. The patient reports having a stiff neck: While a stiff neck may indicate meningeal irritation, which can be associated with a subarachnoid hemorrhage, it is not as immediately concerning as hypotension, which can indicate hypovolemic shock or complications such as vasospasm.

B. The cerebrospinal fluid (CSF) report shows red blood cells (RBCs): The presence of red blood cells in the cerebrospinal fluid is expected in a subarachnoid hemorrhage and is an important diagnostic finding but may not require immediate intervention.

C. The patient reports a severe and unrelenting headache: While a severe and unrelenting headache is a common symptom of subarachnoid hemorrhage, it is not as urgent as addressing hypotension, which can indicate hemodynamic instability and compromise perfusion to vital organs.

D. The patient's blood pressure (BP) is 90/50 mm Hg: Hypotension in a patient with a subarachnoid hemorrhage can indicate hypovolemic shock, vasospasm, or other complications. It is important to communicate this finding promptly to the healthcare provider for further
evaluation and management.

A. Call the health care provider if stools are tarry. B. Clopidogrel will reduce cerebral artery plaque formation. C. Clopidogrel will dissolve clots in the cerebral arteries. D. Monitor and record the blood pressure daily.

Correct Answer is B

Explanation

A. Call the health care provider if stools are tarry: This instruction is more relevant to medications such as aspirin or NSAIDs, which can increase the risk of gastrointestinal bleeding.
Clopidogrel, while also an antiplatelet medication, is less likely to cause gastrointestinal bleeding compared to aspirin.

B. Clopidogrel will reduce cerebral artery plaque formation: Clopidogrel is an antiplatelet
medication that inhibits platelet aggregation, thereby reducing the formation of blood clots and potentially slowing the progression of atherosclerosis by preventing further plaque formation.

C. Clopidogrel will dissolve clots in the cerebral arteries: While clopidogrel can help prevent the formation of new clots, it does not actively dissolve existing clots in the cerebral arteries. Its primary mechanism of action is to inhibit platelet aggregation and prevent clot formation.

D. Monitor and record the blood pressure daily: While monitoring blood pressure is important for managing cerebral atherosclerosis and reducing the risk of stroke, it is not directly related to the action of clopidogrel. Blood pressure management may involve lifestyle modifications and other medications but is not specific to clopidogrel administration.

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Which action should the nurse recognize as the highest priority for a patient who was admitted 16 hours earlier with a C5 spinal cord injury?

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Naxlex Comprehensive Predictor Exams

Which information about the patient who had a subarachnoid hemorrhage is most important to communicate to the health care provider?

Correct Answer is D

Explanation

What will the nurse tell the patient who has cerebral atherosclerosis about taking clopidogrel?

Correct Answer is B

Explanation

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