Difficulty: Medium
Average Score: 81%
Simulated
A client is admitted to the neurological intensive care unit after having just sustained a C5 spinal cord injury (SCI). Which assessment finding for this client warrants immediate intervention by the nurse?
Correct answer
A
Rationale
A C5 spinal cord injury can impair diaphragmatic function and respiratory effort, leading to respiratory failure. Shallow and labored breathing suggests that the client is experiencing respiratory compromise, which can quickly progress to hypoventilation, hypoxia, and respiratory arrest. Immediate intervention, such as assisted ventilation or intubation, may be necessary to maintain adequate oxygenation and prevent further complications.