SPINAL CORD INJURY (PART 2)

The nurse is caring for a client one week after the client experienced a spinal cord injury at the T3 level. What is an appropriate short-term goal for this client? 1. the client will understand limitations 2. the client will consider lifestyle changes 3. the client will perform independent ambulation 4. the client will carry out personal hygiene activities

4 rationale: If the client has the capability to perform personal hygiene activities, it will help maintain a positive identity. Understanding limitations, considering lifestyle changes, and performing independent ambulation are necessary for progression to long-term goals.

A client being treated for a spinal cord injury needs immediate ventilatory support. The nurse realizes that this clients level of injury is most likely: 1. C3. 2. C6. 3. T3. 4. L3.

ANS: 1 High cervical injuries above C3 will result in loss of respiratory function and death unless ventilator support is immediately provided. Spinal cord injuries at C6, T3, or L3 do not need immediate ventilatory support.

A client receiving care for a spinal cord injury complains of a pounding headache, blurred vision, and has a blood pressure of 200/100 mmHg. What is the first action the nurse should take? 1. Administer pain medication. 2. Position the client on the left side. 3. Turn off the lights and decrease the noise in the room. 4. Check the bladder for distension.

ANS: 4 The symptoms suggest autonomic hyperreflexia, a medical emergency. The client should be checked for a distended bladder and be prepared for catheterization. Pain medication, positioning, or reducing environmental stimuli will not treat the underlying cause of autonomic hyperreflexia.

The nurse is caring for a client with a spinal cord injury. Which priority intervention should be performed by the nurse immediately? 1. monitoring urinary output 2. assessing for other injuries 3. infusing lactated Ringer solution 4. immobilizing and stabilizing cervical spine

4 rationale: A client with a spinal cord injury should first have the cervical spine immobilized and stabilized. Monitoring urinary output should be performed during ongoing assessments, after providing initial treatment. The client should be assessed for other injuries after immediate interventions are performed. Ringer solution should be infused after stabilizing oxygen levels and cervical spine.

Which of the following clinical manifestations would the nurse interpret as representing neurogenic shock in a patient with acute spinal cord injury? A. Bradycardia B. Hypertension C. Neurogenic spasticity D. Bounding pedal pulses

A. Bradycardia RATIONALE: Bradycardia is the only manifestation here of neurogenic shock. Patient would be hypotensive with weak pulses.

The nurse is educating a patient and the family about different types of stabilization devices. Which statement by the patient indicates that the patient understands the benefit of using a halo fixation device instead of Gardner-Wells tongs? 1. "I will have less pain if I use the halo device." 2. "The halo device will allow me to get out of bed." 3. "I am less likely to get an infection with the halo device." 4. "The halo device does not have to stay in place as long."

Correct Answer: 2 Rationale: A halo device will allow the patient to be mobile since it does not require weights like the Gardner-Wells tongs. The patient's pain level is not dependant on the type of stabilization device used. The patient does not have a great risk of infection with the Garnder-Wells tongs; both devices require pins to be inserted into the skull. The time required for stabilization is not dependant on the type of stabilization device used.

A patient with a spinal cord injury at the T1 level complains of a severe headache and an "anxious feeling." Which is the most appropriate initial reaction by the nurse? 1. Try to calm the patient and make the environment soothing. 2. Assess for a full bladder. 3. Notify the healthcare provider. 4. Prepare the patient for diagnostic radiography.

Correct Answer: 2 Rationale: Autonomic dysreflexia occurs in patients with injury at level T6 or higher, and is a life-threatening situation that will require immediate intervention or the patient will die. The most common cause is an overextended bladder or bowel. Symptoms include hypertension, headache, diaphoresis, bradycardia, visual changes, anxiety, and nausea. A calm, soothing environment is fine, though not what the patient needs in this case. The nurse should recognize this as an emergency and proceed accordingly. Once the assessment has been completed, the findings will need to be communicated to the healthcare provider.

The nurse is caring for a client in active labor with a history of T5 spinal cord injury. Which of the following findings indicates to the nurse that the client is experiencing a complication of the labor process? 1. increased pulse rate 2. increased urine output 3. increased blood pressure 4. flaccidity in the lower extremities

3 rationale: A client with a spinal cord injury at T6 or higher is at risk for autonomic dysreflexia, marked by increased blood pressure and bradycardia. The nurse will need to carefully monitor this client throughout the labor process. An increased pulse rate may be a result of the adaptation of the labor process. Increased urine output would be expected, because clients are well hydrated in labor; this does not indicate a complication. Flaccidity is an expected assessment finding for a client with this history.

The primary reason the nurse encourages a client with a spinal cord injury to increase oral fluid intake is to prevent which problem? 1. dehydration 2. skin breakdown 3. electrolyte imbalances 4. urinary tract infections

4 rationale: Clients in the early stages of spinal cord damage experience an atonic bladder, which is characterized by the absence of muscle tone, an enlarged capacity, no feeling of discomfort with distention, and overflow with a large residual. This leads to urinary stasis and infection. High fluid intake limits urinary stasis and infection by diluting the urine and increasing urinary output. Dehydration is not a major problem after spinal cord injury. Pressure-relieving devices and position changes are most essential in preventing skin breakdown. An electrolyte imbalance is not a major problem after spinal cord injury.

A nurse is caring for a client with a spinal cord injury during the immediate postinjury period. Which is the priority focus of nursing care during this immediate phase? 1. Inhibiting urinary tract infections 2. Preventing contractures and atrophy 3. Avoiding flexion or hyperextension of the spine 4. Preparing the client for vocational rehabilitation

3 rationale: The priority of care at this time is to protect the spine from additional damage to the traumatized area while it heals. Infection can result from prolonged immobility; although important, it is not the immediate priority. Although important, preventing contractures and atrophy is not the priority in the immediate postinjury period. Vocational rehabilitation will assume greater importance after the client's condition stabilizes.

A nurse provides discharge teaching related to intermittent urinary self-catheterization to a client with a new spinal cord injury. Which instruction is most important for the nurse to include? 1. "Wear sterile gloves when doing the procedure." 2. "Wash your hands before performing the procedure." 3. "Perform the self-catheterization every 12 hours." 4. "Dispose of the catheter after you have catheterized yourself."

2 rationale: To prevent transferring organisms to the urinary system, the client is taught to wash his or her hands thoroughly with soap and water before inserting a clean catheter. Sterile gloves are not required for this procedure in the home care setting. Every 12 hours is too long of a time frame between catheterizations. The client should be taught to recognize when self-catheterization is needed and develop a 2- to 3-hour catheterization schedule. Some home care settings may require the client to clean and re-use catheters.

Which responses should alert the nurse that a client with a spinal cord injury is developing autonomic dysreflexia? 1. flaccid paralysis and numbness 2. absence of sweating and pyrexia 3. escalating tachycardia and shock 4. paroxysmal hypertension and bradycardia

4 rationale: When autonomic dysreflexia is identified, immediate intervention is necessary to prevent serious complications. Paralysis is related to transection, not to dysreflexia; the client will have no sensation below the injury. Profuse diaphoresis occurs. Bradycardia occurs. These clinical findings occur as a result of exaggerated autonomic responses.

A client with quadriplegia is in spinal shock. What finding should the nurse expect? A. Absence of reflexes along with flaccid extremities B. Positive Babinski's reflex along with spastic extremities C. Hyperreflexia along with spastic extremities D. Spasticity of all four extremities

A. Absence of reflexes along with flaccid extremities RATIONALE: Spinal shock causes an absence of reflexes and flaccid extremities

During assessment of a patient with a spinal cord injury at the level of T2 at the rehabilitation center, which of the following findings would concern the nurse the most? A. A heart rate of 92 B. A reddened area over the patient's coccyx C. Marked perspiration on the patient's face and arms D. A light inspiratory wheeze on auscultation of the lungs

C. Marked perspiration on the patient's face and arms RATIONALE: Most concern is the marked perspiration as that could be a sign of autonomic dysreflexia, which requires immediate intervention by the nurse. This is a high priority than the reddened area; HR is normal; light wheeze may be expected.

The client with a C-6 spinal cord injury has come to the emergency department complaining of a throbbing headache and has a B/P of 200/120. What intervention should the nurse implement first? A. Place the client on a telemetry unit. B. Complete a neurological assessment. C. Insert an indwelling urinary catheter. D. Request a STAT CT scan on the head

Correct answer C Insert an indwelling urinary catheter. Rationale: Autonomic dysreflexia is a life-threatening condition and can be considered a medical emergency requiring immediate attention. The nurse should not assess but should intervene, and the most common cause is a full bladder.

The nurse is providing care to a client with a neck and spinal cord injury. Which is the priority when moving this client during the assessment process? 1. Removing the cervical spine collar 2. Monitoring for autonomic dysreflexia 3. Implementing the logrolling technique 4. Administering the prescribed pain medication

3 rationale: The priority when moving a client who presents with a neck and a spinal cord injury is to logroll the client whenever a transfer must occur. The nurse would not remove the cervical spine collar because this can exacerbate the original injury. The nurse would not monitor for autonomic dysreflexia during the acute phase of the injury. While monitoring and addressing pain is important, this is not the priority when transferring this client.

The nurse finds that a client with a spinal cord injury has developed sudden autonomic dysreflexia. What is the priority nursing action in this situation? 1. place in a sitting position 2. give nifedipine as prescribed 3. examine for symptoms of pressure ulcers 4. monitor blood pressure every 10-15 minutes

1 rationale: Clients with spinal cord injuries are at an increased risk for developing autonomic dysreflexia. Autonomic dysreflexia is a condition in which the client has very high blood pressure. The first step in this situation is to assist the client into a sitting position because it naturally reduces blood pressure. The nurse can give nifedipine as prescribed, but only after assisting the client into a sitting position. The nurse can examine the symptoms of pressure ulcers after stabilizing the client. The nurse should monitor client's blood pressure every 10 to 15 minutes after stabilizing the client.

A client who sustained a spinal cord injury experienced an episode of autonomic dysreflexia. Which intervention should the nurse perform first? 1. assess for the cause 2. place the client in sitting position 3. check the client for fecal impaction 4. give an alpha blocker prophylactically

2 rationale: Clients experiencing autonomic dysreflexia should immediately be placed in a sitting position because the condition may cause involuntary nervous system reaction and dangerous spikes in blood pressure. The next step is to assess for the cause for autonomic dysreflexia. Fecal impaction and other colorectal complications are routinely assessed in the client. Alpha blockers can be given to treat recurrent autonomic dysreflexia.

Two weeks after sustaining a spinal cord injury, a client begins vomiting thick coffee-ground material and appears restless and apprehensive. What is the most important initial nursing action? 1. Change the client's diet to bland. 2. Obtain a stool specimen for occult blood. 3. Prepare for insertion of a nasogastric tube. 4. Monitor recent laboratory reports for hemoglobin levels.

3 rationale: The client should have a nasogastric tube inserted to keep the stomach decompressed; the nurse should monitor the amount and characteristics of the drainage. Coffee-ground gastric fluid indicates blood that has been influenced by gastric juices. The healthcare provider should be notified. Changing the client's diet to bland is unsafe; the client needs immediate medical attention. Obtaining a stool specimen for occult blood is indicated at the next bowel movement, but it is not the priority. Monitoring recent laboratory reports for hemoglobin levels is unsafe; the client needs immediate medical attention.

The nurse is planning care for a client who has experienced a T3 spinal cord injury. The nurse should include which intervention in the plan to prevent autonomic dysreflexia (hyperreflexia)? 1. Assist the client to develop a daily bowel routine to prevent constipation. 2. Teach the client to manage emotional stressors by using mental imaging. 3. Assess vital signs and observe for hypotension, tachycardia, and tachypnea. 4. Administer dexamethasone orally per the primary health care provider's prescription

Answer: 1 Rationale: Autonomic dysreflexia is a potentially life-threatening condition and may be triggered by bladder distention, bowel distention, visceral distention, or stimulation of pain receptors in the skin. A daily bowel program eliminates this trigger. Options 3 and 4 are unrelated to this specific condition. A client with autonomic hyperreflexia would be severely hypertensive and bradycardic. Removal of the stimuli results in prompt resolution of the signs and symptoms.

The nurse is planning a discharge teaching plan for a client who sustained a spinal cord injury. To provide for a safe environment regarding home care, which option should be the priority in the discharge teaching plan? 1. Assisting the client to deal with long-term care placement 2. Including the client's significant others in the teaching session 3. Following up on laboratory and diagnostic tests that were prescribed 4. Including information the primary health care provider has indicated

Answer: 2 Rationale: Involving the client's significant others in discharge teaching is a priority in planning for the client with a spinal cord injury. The client will need the support of the significant others. Knowledge and understanding of what to expect will help both the client and significant others deal with the client's limitations. Long-term placement is not the only option for a client with a spinal cord injury. Laboratory and diagnostic testing are not priority discharge instructions for this client. A primary health care provider's prescription is not necessary for discharge planning and teaching; this is an independent nursing action.

The nurse is caring for a client with a diagnosis of a C-6 spinal cord injury during the spinal shock phase. Which action should the nurse implement when preparing the client to sit in a chair? 1. Apply knee splints to stabilize the joints during transfer. 2. Teach the client to lock the knees during the pivoting stage of the transfer. 3. Administer a vasodilator in order to improve circulation of the lower limbs. 4. Raise the head of the bed slowly to decrease orthostatic hypotensive episodes.

Answer: 4 Rationale: Spinal shock is a sudden depression of reflex activity in the spinal cord that occurs below the level of injury (areflexia). It is often accompanied by vasodilation in the lower limbs, which results in a fall in blood pressure upon rising. The client can have dizziness and feel faint. The nurse should provide for a gradual progression in head elevation while monitoring the blood pressure. The use of splints would impair the transfer. Clients with cervical cord injuries cannot lock their knees. A vasodilator would exacerbate the problem

A hospitalized patient with a C7 cord injury begins to yell "I can't feel my legs anymore." Which is the most appropriate action by the nurse? 1. Remind the patient of her injury and try to comfort her. 2. Call the healthcare provider and get an order for radiologic evaluation. 3. Prepare the patient for surgery, as her condition is worsening. 4. Explain to the patient that this could be a common, temporary problem.

Correct Answer: 4 Rationale: Spinal shock is a condition almost half the people with acute spinal injury experience. It is characterized by a temporary loss of reflex function below level of injury, and includes the following symptomatology: flaccid paralysis of skeletal muscles, loss of sensation below the injury, and possibly bowel and bladder dysfunction and loss of ability to perspire below the injury level. In this case, the nurse should explain to the patient what is happening.

The nurse has implemented a plan of care for a client diagnosed with a cervical 5 (C5) spinal cord injury to promote health maintenance. Which client outcome indicates the effectiveness of the plan? 1. Maintenance of intact skin 2. Regaining of bladder and bowel control 3. Performance of activities of daily living independently 4. Independent transfer of self to and from the wheelchair

Answer: 1 Rationale: A C5 spinal cord injury results in quadriplegia with no sensation below the clavicle, including most of the arms and hands. The client maintains the partial movement of the shoulders and elbows. Maintaining intact skin is an outcome for spinal cord injury clients. The remaining options are inappropriate for this client.

When preparing the client with a spinal cord injury who is experiencing bladder spasms and reflex incontinence for discharge to home, the nurse should provide which instruction to prevent the problem? 1. "Avoid caffeine in your diet." 2. "Take your temperature every day." 3. "Limit your fluid intake to 1000 mL per 24 hours." 4. "Catheterize yourself every 2 hours as needed to prevent spasm."

Answer: 1 Rationale: Caffeine in the diet can contribute to bladder spasms and reflex incontinence; thus, it should be eliminated in the diet of the client with a spinal cord injury. The self-monitoring of the temperature is useful to detect infection, but it does nothing to alleviate bladder spasms. Limiting fluid intake does not prevent spasm, and it could place the client at further risk for urinary tract infection. Self-catheterization every 2 hours is too frequent and serves no useful purpose.

A patient with a spinal cord injury (SCI) is admitted to the unit and placed in traction. Which of the following actions is the nurse responsible for when caring for this patient? Select all that apply. 1. modifying the traction weights as needed 2. assessing the patient's skin integrity 3. applying the traction upon admission 4. administering pain medication 5. providing passive range of motion

Correct Answer: 2,4,5 Rationale: The healthcare provider is responsible for initial applying of the traction device. The weights on the traction device must not be changed without the order of a healthcare provider. When caring for a patient in traction, the nurse is responsible for assessment and care of the skin due to the increased risk of skin breakdown. The patient in traction is likely to experience pain and the nurse is responsible for assessing this pain and administering the appropriate analgesic as ordered. Passive range of motion helps prevent contractures; this is often performed by a physical therapist or a nurse.

A nurse is caring for a client who has paraplegia as a result of a spinal cord injury. Which rehabilitation plan will be most effective for this client? 1. Arrangements will be made by the client and the client's family. 2. The plan is formulated and implemented early in the client's care. 3. The rehabilitation is minimal and short term, because the client will return to former activities. 4. Arrangements will be made for long-term care, because the client is no longer capable of self-care.

2 rationale: To promote optimism and facilitate smooth functioning, rehabilitation planning should begin on admission to the hospital. The client and family often are unaware of the options available in the healthcare system; the nurse should be available to provide the necessary information and support. Rehabilitation helps a client adjust to a new lifestyle that must compensate for the paralysis. The goal of rehabilitation is to foster independence wherever the client may live after discharge.

The nurse is caring for a client with a spinal cord injury who has paraplegia. The nurse can expect which major problem early in the recovery period? 1. bladder control 2. nutritional intake 3. quadriceps setting 4. use of aids for ambulation

1 rationale: Because of the location of the micturition reflex center (in the sacral region of the spinal cord), bladder function may be impaired with lower spinal cord injuries. This client's ability to ingest, digest, or metabolize food is not affected; therefore nutrition is less of a problem than bladder control. Quadriceps settings require motor control, which the client does not have. Because there is no voluntary control over the lower extremities, mobility usually is accomplished through the use of a wheelchair rather than ambulation.

The nurse is caring for a client with a spinal cord injury. Which assessment findings alert the nurse that the client is developing autonomic hyperreflexia (autonomic dysreflexia)? 1. hypertension and bradycardia 2. flaccid paralysis and numbness 3. absence of sweating and pyrexia 4. escalating tachycardia and shock

1 rationale: Hypertension and bradycardia occur as a result of exaggerated autonomic responses. If autonomic hyperreflexia is identified, immediate intervention is necessary to prevent serious complications. Paralysis is related to transection, not autonomic hyperreflexia; the client will have no sensation below the injury. Profuse diaphoresis occurs above the level of injury. Bradycardia occurs.

A client is admitted to the emergency department with the diagnosis of a possible spinal cord injury. The nurse should monitor the client for what clinical manifestations of spinal shock? Select all that apply. 1. bradycardia 2. hypotension 3. spastic paralysis 4. bladder dysfunction 5. increased pulse pressure

1, 2, 4 rationale: Bradycardia occurs with spinal shock because the vascular system below the level of injury dilates and the cardiac accelerator reflex is suppressed. Initially there is a loss of vascular tone below the injury, resulting in hypotension. Bladder dysfunction in the form of urinary retention or oliguria may occur in spinal shock. Initially, flaccid paralysis is associated with spinal shock; as spinal shock subsides, spastic paralysis develops. There is a decreased, not increased, pulse pressure associated with hypotension and shock

A client has a functional transection of the spinal cord at C7-8, resulting in spinal shock. Which clinical indicators does the nurse expect to identify when assessing the client immediately after the injury? Select all that apply. 1. spasticity 2. incontinence 3. flaccid paralysis 4. respiratory failure 5. lack of reflexes below the injury

3, 5 rationale: Spinal shock (spinal shock syndrome) is immediate after a transection of the spinal cord; it results in flaccid paralysis of all skeletal muscles and usually lasts for 48 hours, but may persist for several weeks. Spinal shock is caused by transection of the spinal cord and results in a loss of reflex activity below the level of the injury. Spasticity occurs after spinal shock has subsided. During the acute phase, retention of urine and feces occurs as a result of decreased tone of the bladder and bowel; thus, incontinence is unusual. Respirations are labored, but spontaneous breathing continues, indicating that the level of injury is below C4 and respirations are not affected.

A nurse is caring for a client with a complete T5 spinal cord injury. Upon assessment, the nurse notes flushed skin, diaphoresis above T5, and a blood pressure of 162/96 mm Hg. The client reports a severe, pounding headache. Which nursing interventions are appropriate for this client? Select all that apply. A. Elevating the head of the bed 90 degrees B. Loosening constrictive clothing C. Using a fan to reduce diaphoresis D. Assessing for bladder distention and bowel impaction E. Administering antihypertensive medication F. Placing the client in a supine position with legs elevated

A. Elevating the head of the bed 90 degrees B. Loosening constrictive clothing D. Assessing for bladder distention and bowel impaction E. Administering antihypertensive medication RATIONALE: Patient is displaying signs of autonomic dysreflexia A- True, sit the patient all the way up to help induce hypotension B - True, constrictive clothing can trigger autonomic dysreflexia C - False. Reduce diaphoresis by fixing the problem! D - True. Most commonly caused by bowel/bladder distension E - True. May be needed to reduce severe BP F - False. Patient should be sat up. Could worsen severe BP

A school nurse is called after a student falls down a flight of stairs. The student is breathing, but unconsciousness. After calling the ambulance, which is the most appropriate action by the nurse? 1. Protect the patient's neck and head from any movement. 2. Place the patient on his side to prevent aspiration. 3. Immobilize the neck,,securing the head. 4. Try to rouse the patient by gently shaking his shoulders.

Correct Answer: 3 Rationale: Guidelines for emergency care are avoiding flexing, extending, or rotating the neck; immobilizing the neck; securing the head; maintaining the patient in the supine position; and transferring from the stretcher with backboard in place to the hospital bed. This patient is unconscious, and the nurse must protect the neck from any (or any further) damage. If the patient vomits, the nurse should utilize the log-roll technique to turn the patient while keeping the head, neck, and spine in alignment. Rousing the patient by shaking could cause damage to the spinal cord.

A nurse is caring for a client who experienced a cervical spine injury 3 months ago. The nurse should plan to implement which of the following types of bladder management methods? A. Condom catheter B. Intermittent urinary catheterization C. Credé's method D. Indwelling urinary catheter

Correct answer A Condom catheter. Rationale: The nurse should implement the noninvasive use of a condom catheter, because the bladder will empty on its own due to the client having an upper motor neuron injury, which is manifested by a spastic bladder.

A nurse is caring for a client who was recently admitted to the emergency department following a head-on motor vehicle crash. The client is unresponsive, has spontaneous respirations of 22/min, and has a laceration on his forehead that is bleeding. Which is the priority nursing action at this time? A. Keep neck stabilized. B. Insert nasogastric tube. C. Monitor pulse and blood pressure frequently. D. Establish IV access and start fluid replacement

Correct answer A Keep neck stabilized Rationale: The greatest risk to the client is permanent damage to the spinal cord if a cervical injury does exist. The priority nursing intervention is to keep the neck immobilized until damage to the cervical spine can be ruled out.

A nurse is planning care for a client who has a spinal cord injury (SCI) involving a T12 fracture 1 week ago. The client has no muscle control of the lower limbs, bowel, or bladder. Which of the following should be the nurse's highest priority? A.Prevention of further damage to the spinal cord B. Prevention of contractures of the lower extremities C. Prevention of skin breakdown of areas that lack sensation D. Prevention of postural hypotension when placing the client in a wheelchair

Correct answer A Prevention of further damage to the spinal cord. Rationale: The greatest risk to the client during the acute phase of an SCI is further damage to the spinal cord. When planning care, the priority intervention the nurse should take is to prevent further damage to the spinal cord by administration of corticosteroids, minimizing movement of the client until spinal stabilization is accomplished through either traction or surgery, and adequate oxygenation of the client to decrease ischemia of the spinal cord.

Which client should the charge nurse assess first after receiving the change-of-shift report? A. The client with a C-6 SCI who is complaining of dyspnea and has a respiratory rate of 12 breaths/min. B. The client with an L-4 SCI who is frightened about being transferred to the rehabilitation unit. C. The client with an L-2 SCI who is complaining of a headache and feeling very hot all of a sudden. D. The client with a C-4 SCI who is on a ventilator and has a pulse oximeter reading of 98%.

Correct answer A The client with a C-6 SCI who is complaining of dyspnea and has a respiratory rate of 12 breaths/min. Rationale: The client with dyspnea and a RR of 12 has s/s of respiratory complications and should be assessed first because ascending paralysis at the C-6 level could cause the client to stop breathing.

A nurse is caring for a client who has a C4 spinal cord injury. Which of the following should the nurse recognize the client as being at the greatest risk for? A. Neurogenic shock. B. Paralytic ileus. C.Stress ulcer. D.Respiratory compromise

Correct answer D Respiratory compromise. Rationale: Using the airway, breathing, and circulation (ABC) priority-setting framework, the greatest risk to the client with an SCI at the level of C4 is respiratory compromise secondary to involvement of the phrenic nerve. Maintenance of an airway and provision of ventilatory support as needed is the priority intervention.