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 A
Explanation
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Correct Answer is A
Explanation
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D. Hypotension with bradycardia does not correlate with autonomic dysreflexia and suggests other health complications.