The nurse always treats multiple trauma victims as if a spine injury exists
Which assessment findings would the nurse evaluate as increasing the risk for the presence of a cervical spine injury? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. The patient is confused and lethargic.
2. The patient has severe facial bruising and trauma.
3. The patient has severe open abdominal wounds.
4. The patient has an obvious depressed skull fracture.
5. The patient cannot follow commands.
1,2,4,5
Rationale 1: Patients who have an altered level of consciousness should be treated as if they have a cervical spine injury until proven otherwise.
Rationale 2: Patients who have had blunt trauma above the clavicle should be treated as if they have a cervical spine injury until proven otherwise.
Rationale 3: Severe open abdominal wounds do not increase the need for surveillance above the normal spinal precautions.
Rationale 4: Patients who have had blunt trauma above the clavicle should be treated as if they have a cervical spine injury until proven otherwise.
Rationale 5: Patients who have an altered level of consciousness should be treated as if they have a cervical spine injury until proven otherwise.
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