A client arrives to the emergency department after falling from a ladder. The client has a loss of sensation and flaccid paralysis. Which of the following complications of an acute spinal cord injury does the nurse suspect?
Hemorrhage
Spinal shock
Apoptosis
Neurogenic shock
The Correct Answer is B
Choice A Reason: Hemorrhage is not a complication of an acute spinal cord injury, but rather a possible cause of it. Hemorrhage can occur due to trauma or rupture of blood vessels in or around the spinal cord, leading to compression and damage of the nerve tissue.
Choice B Reason: This is the correct choice. Spinal shock is a complication of an acute spinal cord injury that occurs within minutes to hours after the injury. It is characterized by loss of sensation, motor function, reflexes, and autonomic function below the level of injury. It is caused by transient disruption of nerve conduction and synaptic transmission in the spinal cord.
Choice C Reason: Apoptosis is not a complication of an acute spinal cord injury, but rather a cellular process that occurs after it. Apoptosis is programmed cell death that occurs in response to injury or stress. It can lead to further loss of neurons and glial cells in the spinal cord over time.
Choice D Reason: Neurogenic shock is a complication of an acute spinal cord injury that occurs within hours to days after the injury. It is characterized by hypotension, bradycardia, and peripheral vasodilation due to loss of sympathetic tone and unopposed parasympathetic activity. It is caused by disruption of autonomic pathways in the spinal cord.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A Reason: The client needs total nursing care is the expected outcome for a client who has a score of 6 on the Glasgow Coma Scale, which is a tool that measures the level of consciousness based on eye opening, verbal response, and motor response. A score of 6 indicates severe brain injury and coma, meaning that the client is unresponsive and dependent on others for all activities of daily living.
Choice B Reason: Indicates stable neurologic status is not the expected outcome for a client who has a score of 6 on the Glasgow Coma Scale, which indicates severe brain injury and coma. A stable neurologic status means that there are no changes in the level of consciousness, vital signs, or neurological signs.
Choice C Reason: The client has a decline in level of consciousness but is able to protect his airway is not the expected outcome for a client who has a score of 6 on the Glasgow Coma Scale, which indicates severe brain injury and coma. A decline in level of consciousness means that the client is less alert and responsive than normal, but still able to respond to stimuli and maintain airway patency.
Choice D Reason: The client is alert and oriented is not the expected outcome for a client who has a score of 6 on the Glasgow Coma Scale, which indicates severe brain injury and coma. Alert and oriented means that the client is fully awake and aware of person, place, time, and situation.
Correct Answer is A
Explanation
Choice A reason: This is the correct answer because this question will help the nurse assess the pain level and discomfort of the client with red scaling papules. Red scaling papules are raised skin lesions that are red and covered with scales. They can indicate psoriasis, which is a chronic skin condition that causes inflammation and rapid turnover of skin cells. Psoriasis can cause pain, itching, burning, or stinging sensations in the affected areas. The nurse should ask the client to rate their pain on a numeric or descriptive scale and provide analgesics or topical agents as prescribed.
Choice B reason: This is incorrect because this question will not help the nurse assess the condition of the client with red scaling papules. Red scaling papules are not affected by food intake but by other factors such as stress, infection, injury, or medication. Psoriasis is not an allergic or dietary disorder, but an immune-mediated disorder that causes abnormal skin cell growth. The nurse should ask the client about their medical history, current medications, and triggers or aggravating factors for their psoriasis.
Choice C reason: This is incorrect because this question will not help the nurse assess the condition of the client with red scaling papules. Red scaling papules are not treated with antibiotics but with other medications such as corticosteroids, immunosuppressants, or biologics. Antibiotics are used to treat bacterial infections, which are not the cause of psoriasis. The nurse should ask the client about their treatment regimen, compliance, and effectiveness for their psoriasis.
Choice D reason: This is incorrect because this question will not help the nurse assess the condition of
the client with red scaling papules. Red scaling papules are not related to weekend activities but to chronic skin inflammation and abnormal cell turnover. Psoriasis is not a lifestyle disorder, but a genetic disorder that can be influenced by environmental factors. The nurse should ask the client about their family history, exposure to sun or cold, and stress level for their psoriasis.
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