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.
Free Nursing Test Bank
- Free Pharmacology Quiz 1
- Free Medical-Surgical Quiz 2
- Free Fundamentals Quiz 3
- Free Maternal-Newborn Quiz 4
- Free Anatomy and Physiology Quiz 5
- Free Obstetrics and Pediatrics Quiz 6
- Free Fluid and Electrolytes Quiz 7
- Free Community Health Quiz 8
- Free Promoting Health across the Lifespan Quiz 9
- Free Multidimensional Care Quiz 10
View Related questions
Correct Answer is A
Explanation
A. Chvostek's sign, a facial muscle spasm upon tapping, is a clinical indicator of hypocalcemia, often caused by accidental removal or damage to the parathyroid glands during thyroid surgery.
B. Hypercalcemia does not typically cause a positive Chvostek’s sign.
C. Hypokalemia affects muscle and cardiac function but does not result in a positive Chvostek’s sign.
D. Hyponatremia does not produce Chvostek's sign, which is specific to hypocalcemia.
Correct Answer is B
Explanation
A. Turning the client onto their operative side could increase pressure on the eye and is not an appropriate first action.
B. Administering prescribed pain medication and antiemetic is essential to address the client's severe pain and nausea, which are priority concerns in the postoperative period.
C. While it may be necessary to notify the surgeon if symptoms persist, the immediate priority is to alleviate the client's discomfort.
D. Reassuring the client that these symptoms are normal is misleading; severe pain and nausea postoperatively should be addressed promptly.