The nurse is caring for a patient in the acute care setting with a spinal cord injury (SCI) at the level of C-3. What is the main cause of complications or death related to this injury?
Bradycardia
Sepsis
Hypertension
Respiratory compromise
The Correct Answer is D
A. Bradycardia is possible due to autonomic dysfunction but is not the leading cause of death.
B. Sepsis can occur due to immobility and pressure injuries but is secondary to respiratory compromise.
C. Hypertension is not directly linked to high cervical spine injuries and is less common than respiratory issues in this setting.
D. Respiratory compromise is the primary cause of complications or death in patients with a high cervical spine injury (C-3 and above) due to loss of innervation to the diaphragm and intercostal muscles, which impairs spontaneous breathing. Mechanical ventilation is often required to maintain adequate oxygenation.
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Correct Answer is D
Explanation
A. The head tilt chin lift method should be avoided due to the risk of aggravating a spinal injury; the jaw-thrust maneuver is safer if airway management is necessary.
B. While controlling bleeding is important, cervical spine stabilization takes priority in trauma with suspected spinal injury.
C. Not moving the victim is appropriate, but stabilizing the cervical spine provides active support to avoid further injury.
D. Stabilizing the cervical spine is crucial to prevent potential spinal cord damage in an unconscious trauma victim, particularly in a motor vehicle accident. This action helps prevent exacerbation of any spinal injury.
Correct Answer is C
Explanation
A. While anxiety can cause gastrointestinal symptoms, the context of this patient’s experience with seizures indicates that it is specifically related to the seizure disorder rather than an independent anxiety issue.
B. The sensation of "butterflies" is not typically related to hunger, as hunger is more commonly associated with physical feelings of emptiness or pain rather than a specific butterfly sensation.
C. An aura is a perceptual disturbance experienced by some patients with seizure disorders that precedes a seizure. It can manifest as various sensations, including gastrointestinal feelings like "butterflies," which serve as a warning sign that a seizure is imminent.
D. A postictal sign refers to the state of confusion or altered consciousness following a seizure, rather than sensations experienced prior to the seizure.