The Emergency Department nurse is expecting a patient with a spinal cord transection at C1. Which of the following assessments take priority upon the patient's arrival? (SELECT ALL THAT APPLY)
Blood pressure
Bladder function
Heart rate
Reflexes
Respirations
Correct Answer : A,C,E
A. Blood pressure monitoring is essential, as spinal cord injuries at high levels can cause disruptions in autonomic regulation, leading to significant blood pressure fluctuations.
B. Bladder function is impacted by spinal cord injuries; however, it is not the initial priority in an emergency setting when life-threatening complications must be managed first.
C. Heart rate is critical as high spinal cord injuries can impact cardiac function by affecting autonomic control, potentially leading to bradycardia.
D. Reflexes are often assessed in cases of spinal injury, but they are not the immediate priority when stabilizing the patient upon arrival.
E. Respirations are a priority, as a C1 spinal cord injury can compromise respiratory function, necessitating immediate assessment to ensure adequate oxygenation and airway management.
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Correct Answer is B
Explanation
A. Scheduled voiding is less effective in patients with a flaccid bladder because there is no voluntary control of bladder function.
B. Intermittent catheterization is the preferred management technique for a flaccid or atonic bladder, allowing the bladder to empty at regular intervals and reducing the risk of infection associated with continuous catheters.
C. An indwelling catheter is usually avoided for long-term use due to a higher risk of infection.
D. An external catheter is generally not effective for flaccid or atonic bladder management in spinal cord injuries as it doesn’t actively empty the bladder.
Correct Answer is A
Explanation
A. A cold, pulseless foot indicates compromised blood flow, a medical emergency following an arteriogram. The nurse should immediately notify the physician to address potential vascular occlusion.
B. Elevating the limb can further impair circulation if blood flow is already compromised.
C. Covering the limb will not address the underlying issue of impaired circulation.
D. Repositioning may delay timely intervention in what may be a vascular emergency.