A nurse is in the emergency department (ED) and is caring for a client that has arrived by ambulance after a cervical spinal cord injury. Which assessment should be the priority for the nurse to perform at this time?
Assess the client's respiratory status and airway patency.
Assess the client's extremity strength and sensation.
Assess the client's pain level and provide pain management.
Assess the client's level of consciousness and orientation.
The Correct Answer is A
A. Assessing respiratory status and airway patency is the highest priority in this situation due to the risk of respiratory compromise from cervical spinal cord injuries, which can affect the diaphragm and other respiratory muscles.
B. While assessing extremity strength and sensation is important, it comes after ensuring the client’s airway and breathing are stable.
C. Pain management is essential, but addressing immediate life-threatening conditions takes precedence over pain assessment.
D. Assessing the client's level of consciousness is crucial for overall evaluation but does not take priority over ensuring adequate respiratory function in the context of a cervical spinal cord injury.
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Correct Answer is B
Explanation
A. The Glasgow Coma Scale is useful for assessing consciousness levels but may not be as sensitive for changes in brainstem function in a patient already in an induced coma.
B. Assessing pupillary size and reaction provides critical information on brainstem function and can indicate changes in ICP. Changes in pupil size and reaction can signify worsening cerebral function or brain herniation.
C. Blood pressure and heart rate are vital signs that can suggest increased ICP, but they are not as direct an indicator of cerebral function as pupil assessment.
D. The gag reflex is important but does not provide as direct information about cerebral function related to ICP as pupillary assessment does.
Correct Answer is B
Explanation
A. Serum thyroxine (T4) is typically decreased in primary hypothyroidism due to reduced thyroid hormone production.
B. In primary hypothyroidism, the thyroid gland fails to produce sufficient hormones, which leads to an increase in thyroid-stimulating hormone (TSH) as the pituitary gland tries to stimulate thyroid function. Elevated TSH is a common finding in primary hypothyroidism.
C. Serum T3 is usually decreased in primary hypothyroidism since the production of T3 and T4 is reduced.
D. Free T4 is typically low in primary hypothyroidism as the thyroid gland is underactive and not producing adequate levels of thyroid hormones.