Difficulty: Medium
Average Score: 72%
Simulated
The nurse in the neurointensive care unit is caring for a client with a new Cervical SCI who is breathing independently. Which nursing interventions should be implemented? Select all that apply.
Correct answer
A,C,D
Rationale
Cervical SCI risks respiratory compromise and autonomic dysreflexia. Monitoring pulse oximetry (A) ensures oxygenation, coughing/deep breathing (C) prevents pneumonia, and assessing for autonomic dysreflexia (D) detects dangerous BP spikes. Pureed foods (B) are unnecessary without dysphagia, and corticosteroids (E) are not standard for acute SCI management.