A 14-year-old girl is in the intensive care unit after a spinal cord injury 2 days ago. What nursing intervention is a priority for this child?
a. Minimizing environmental stimuli
b. Administering immunoglobulin
c. Monitoring and maintaining systemic blood pressure
d. Discussing long-term care issues with the family
ANS: C
Spinal cord injury patients are physiologically labile, and close monitoring is required. They may be unstable for the first few weeks after the injury. Increased blood pressure may be an indication of autonomic dysreflexia. It is not necessary to minimize environmental stimuli for this type of injury. Spinal cord injury is not an infectious process. Immunoglobulin is not indicated. Discussing long-term care issues with the family is inappropriate. The family is focusing on the recovery of their child. It will not be known until the rehabilitation period how much function the child may recover.
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