A client who sustained an L-1 spinal cord injury six months ago that resulted in paraplegia is now experiencing spastic muscle movements in the lower extremities. Which intervention should the nurse implement?

Perform active range of motion exercises.

Apply compression stockings.

Give antispasmodic medications.

Massage the extremities twice a week.

Answer and Explanation

The Correct Answer is C

A. Perform active range of motion exercises: Active ROM exercises are beneficial for maintaining joint mobility and circulation, but they may not sufficiently reduce spasticity in clients with upper motor neuron lesions.

B. Apply compression stockings: Compression stockings help prevent venous thromboembolism and manage edema, but they do not treat muscle spasticity. They offer circulatory support, not neuromuscular control, and therefore would not alleviate the client’s current concern.

C. Give antispasmodic medications: Antispasmodics such as baclofen or tizanidine directly target muscle spasticity by acting on the central nervous system. These medications reduce the frequency and intensity of spasms, improving comfort and mobility in clients with spinal cord injuries.

D. Massage the extremities twice a week: Massage may offer relaxation and temporary relief but is not a primary treatment for spasticity. It does not alter the neurophysiological causes of muscle spasms and is unlikely to produce sustained control over involuntary muscle activity.

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Correct Answer is C

Explanation

A. Instruct the client to cough as the suction tip is removed: Coughing can help clear secretions, but this action is not the primary safety concern during suctioning. The priority is minimizing the risk of injury, infection, and contamination during the procedure

B. Instil 3 mL of 0.9% sodium chloride before suctioning: Instilling saline before suctioning is generally not recommended as it can lead to complications, such as increasing mucus production, which can make suctioning more difficult.

C. Wear protective goggles while performing the procedure: Suctioning a tracheostomy can involve secretions that may potentially splash, so it’s important to wear protective goggles, as well as other appropriate personal protective equipment, to ensure safety and prevent contamination.

D. Apply a water-soluble lubricant to the catheter: Applying lubricant to the catheter is not recommended. The suction catheter should be kept sterile and dry to avoid introducing any contaminants into the trachea or the airway.

A. Demonstrate to the PN how to position the client more effectively for the procedure. B. Arrange for unlicensed assistive personnel to assist the PN during the procedure. C. Acknowledge that the PN has positioned the client safely and correctly. D. Assume care of the client and assign the PN to the care of a different client.

Correct Answer is A

Explanation

A. Demonstrate to the PN how to position the client more effectively for the procedure:
The correct position for a sigmoidoscopy is the left lateral or Sims' position to allow easier access to the sigmoid colon. Demonstrating the correct position supports patient safety and provides teaching for the PN.

B. Arrange for unlicensed assistive personnel to assist the PN during the procedure: Assistance is not the issue in this scenario; the problem lies in incorrect positioning. Assigning additional help does not address the need to correct the client's position.

C. Acknowledge that the PN has positioned the client safely and correctly: The flat prone position is not appropriate for a sigmoidoscopy. Acknowledging incorrect positioning would be unsafe and potentially delay the procedure or increase the risk of injury.

D. Assume care of the client and assign the PN to the care of a different client: This is an excessive response that undermines the PN’s role. The more constructive approach is to guide and support the PN through demonstration rather than reassignment.

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A client who sustained an L-1 spinal cord injury six months ago that resulted in paraplegia is now experiencing spastic muscle movements in the lower extremities. Which intervention should the nurse implement?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

When performing suctioning for a client with a tracheostomy, which action should the nurse include?

Correct Answer is C

Explanation

The nurse is setting up the equipment to assist with a sigmoidoscopy while the practical nurse (PN) positions the client in a flat prone position. Which action should the nurse implement?

Correct Answer is A

Explanation

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