A client admitted 3 days prior with an injury to the thoracic ...

[berenicecastro]

A client admitted 3 days prior with an injury to the thoracic area of the spinal cord tells the nurse, I'm getting worse. It's harder to breathe. Based on this data, which does the nurse suspect?
 
  A) The client has atelectasis.
  B) The extent of injury cannot yet be determined.
  C) The client is improving.
  D) The client is developing pneumonia.

Question 2

An adolescent is brought into the emergency department (ED) with injuries sustained from a motor vehicle crash. What should the nurse ensure while caring for this client?
 
  A) An adequate urine output
  B) Stable blood pressure
  C) Stabilization of the neck and spinal cord
  D) Intravenous access line

[BAOCHAU2803]

Answer to Question 1

Answer: B

With a spinal cord injury, there is an area of ischemia and edema. Because edema extends from the level of injury for two cord segments above and below the affected level, the extent of injury cannot be determined for up to 1 week. The client's complaint of it being harder to breathe could be evidence that extent of injury is becoming more obvious but will not be totally determined for a few more days. The client's complaint of it being harder to breathe may or may not indicate pneumonia or atelectasis. The complaint is not evidence that the client is improving.

Answer to Question 2

Answer: C

The danger of death from a spinal cord injury is greatest when there is damage to or transection of the upper cervical region. All people who have sustained trauma to the spine should be treated as though they have a spinal cord injury by stabilizing the neck and spinal cord. Assessment of urine output can be delayed. Assessing blood pressure is an intervention for all clients brought into the Emergency Department. An intravenous access line is necessary, but the stabilization of the neck and spinal cord is of first priority.

[berenicecastro]

Thank you

[BAOCHAU2803]

Happy to help you