Get ready for NCLEX success with today’s question: What’s the first action the nurse should take when responding to an adult client who has fallen from a roof and is suspected of having neurogenic shock? Can you identify the priority intervention?
The nurse is responding to an accident scene where an adult client fell off their roof and is suspected of having neurogenic shock. Which is the first action the nurse should take?
A. Initiate resuscitative intravenous fluids
B. Stabilize the client’s spine using a cervical collar
C. Notify the client’s primary care physician
D. Administer supplemental oxygen
Scroll down for the correct answer!
The correct answer to today’s NCLEX-RN® Question is…
B. Stabilize the client’s spine using a cervical collar
Rationale: After a client sustains a possible spinal cord injury, the nurse should first stabilize the spine using a cervical collar.
Major Takeaway
Neurogenic shock is a type of distributive shock where damage to the brain or spinal cord causes dysregulation of the cardiovascular system, leading to decreased heart rate and vasodilation, which eventually leads to impaired tissue perfusion. The first steps in managing a client with suspected neurogenic shock are to stabilize their spine using a cervical collar, secure the airway, and then provide oxygen. Some clients might also need mechanical ventilatory support. The management continues with early resuscitation with intravenous (IV) fluids and administration of vasoactive medications like norepinephrine. In the case of persistent bradycardia, atropine can be used to increase the heart rate. Clients with neurogenic shock might also benefit from the administration of corticosteroids, such as methylprednisolone.
Incorrect answer explanations
A. Initiate resuscitative intravenous fluids
Rationale: For clients suspected of neurogenic shock, the nurse should plan to initiate resuscitative intravenous fluids early in treatment; however, this is not the nurse’s first action when responding to the scene.
C. Notify the client’s primary care physician
Rationale: Although the nurse should notify the client’s physician in a timely fashion, there is another action that should be taken first.
D. Administer supplemental oxygen
Rationale: For clients suspected of neurogenic shock, the nurse should plan to apply supplemental oxygen. However, this is not the nurse’s first action when responding to the scene.
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