A 22-year old patient involved in a motorcycle accident has a complete transection of the spinal cord at T-8 resulting in paraplegia. Nursing interventions includes repositioning the patient every 1-2 hours to:
Improve venous circulation and prevent VTE formation
Prevent flexion and contractures of the extremities
Decrease the development of a paralytic ileus
Prevent the development of pressure ulcers
The Correct Answer is D
A. Improve venous circulation and prevent VTE formation. – Incorrect. While repositioning does help with circulation, it is primarily done to prevent pressure injuries.
B. Prevent flexion and contractures of the extremities. – Incorrect. Contracture prevention is important, but passive ROM exercises are more effective for this purpose.
C. Decrease the development of a paralytic ileus. – Incorrect. Paralytic ileus is managed through bowel programs and early mobility, not repositioning alone.
D. Prevent the development of pressure ulcers. – Correct Answer. Paralyzed patients are at high risk for pressure ulcers, especially over bony prominences like the sacrum. Repositioning reduces prolonged pressure, which can lead to skin breakdown.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. 8:00 AM to 11:00 AM. – Incorrect. NPH insulin peaks in 6–14 hours, not within a few hours.
B. 2:00 PM to 5:00 PM. – Correct Answer. NPH insulin peaks around 6–14 hours, making this the most likely time for hypoglycemia.
C. 2:00 AM to 5:00 AM. – Incorrect. This would be the peak time for evening NPH insulin, not morning administration.
D. 10:00 PM to 12:00 AM. – Incorrect. NPH insulin does not peak this late when given in the morning.
Correct Answer is C
Explanation
A. Encourage the patient to ask for assistance. – Patients with Alzheimer's often forget to ask for help, making this an unreliable safety measure.
B. Keep the call light near the patient. – The patient may not remember to use the call light.
C. Place the patient in a room close to the nurses' station. – Correct Answer. This allows frequent observation and quick intervention to prevent falls.
D. Remind the patient to walk with someone for support. – Reminders may not be effective due to memory impairment.
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