The nurse is caring for a client who fell off the ladder. The client reports numbness in his lower extremities. The nurse should initially
The nurse is caring for a client who fell off the ladder. The client reports numbness in his lower extremities. The nurse should initially
A. assess the client for lacerations
[8%]
B. evaluate the range of motion of the client's neck
[3%]
C. provide cervical spine stabilization
[67%]
D. assess the client's range of motion in the lower extremities
[22%]
Statistics
Subject/Lesson
Subject
Leadership & Management
Lesson
Management Concepts
Client Need
Test Plan
Management of Care
Related Topic
Establishing Priorities
Item Type
Item Type
Analysis
Explanation
Choice C is correct. The highest priority action would be to stabilize the client's cervical spine. The client is at risk for further injury if the cervical spine is not stabilized and the client moves. A computed tomography scan of the head and neck should be ordered for this client to determine if the client has any neurological injury and cervical spine trauma.
Choice A is incorrect. The client should be assessed for any lacerations. However, this is not the priority action considering the high risk of injury for not stabilizing the client's cervical spinal column.
Choice B is incorrect. The nurse must keep the client's neck stable and not assess range of motion. This is necessary until cervical spinal cord injury can be ruled out.
Choice D is incorrect. The priority is to stabilize the client's cervical spinal column before further assessment of the client's lower extremities. A collar is commonly used to stabilize the client's neck until imaging (CT scan) can exclude a cervical spinal cord injury.
Related Videos
2 Key Topics
ABCs: Airway
15.5 Prioritization Part 1
Additional Info
✓ Stabilizing the client's cervical spinal cord with a c-collar is commonly used for injuries to the spinal column.
✓ Providing this stabilization will prevent further injury, such as paralysis to the lower extremities.
✓ The cervical spine must be treated as unstable until proven otherwise in any situation in which traumatic injury, especially head injury, is the cause of the client's visit to the ED.
