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","D","E"]

Explanation

A. Use standard precautions and wear a mask: Standard precautions are necessary for all patients, but wearing a mask is not specifically required for MRSA unless there is suspicion of respiratory involvement. The focus should be on contact precautions rather than masking.

B. Explain the purpose of a low bacteria diet: A low bacteria diet is not necessary for a client with MRSA unless the client is immunocompromised. The main focus should be on preventing MRSA transmission and managing the infection at the wound site.

C. Send wound drainage for culture and sensitivity: Sending the wound drainage for culture and sensitivity is essential for identifying the causative organism and determining appropriate antibiotic treatment for MRSA. This helps guide therapy and ensure proper management.

D. Institute contact precautions for staff and visitors: Contact precautions are critical for preventing spread of MRSA, especially in wound care situations. The nurse should ensure all staff and visitors follow these precautions to protect others and minimize transmission risk.

E. Monitor the client's white blood cell count: Monitoring the white blood cell count is important as it helps assess the client's immune response to infection. An elevated count may indicate the presence of infection, and close monitoring helps guide treatment decisions.

A. Frequency that the child uses a rescue inhaler during the week. B. Type of inhaler the child typically uses on a regular basis. C. Type of allergen exposure or trigger for the current episode. D. Last dose and type of rescue inhaler used by the child.

Correct Answer is D

Explanation

A. Frequency that the child uses a rescue inhaler during the week: While it is important to know how often the child uses a rescue inhaler, it does not provide immediate, critical information to assess the severity of the current asthma attack.

B. Type of inhaler the child typically uses on a regular basis: While knowing the type of inhaler the child uses regularly can provide insight into their asthma management, it is not the most critical information at this moment, the current treatment is he most urgent.

C. Type of allergen exposure or trigger for the current episode: Understanding the trigger for the current asthma episode is helpful for long-term management but is not as urgent in the immediate assessment of the child’s condition during an acute exacerbation.

D. Last dose and type of rescue inhaler used by the child: This information helps assess whether the child has received appropriate treatment and whether additional or different interventions are needed immediately to address the asthma exacerbation, helps guide further treatment decisions.

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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?

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Naxlex Comprehensive Predictor Exams

A client with foul-smelling drainage from an incision on the upper left arm is admitted with a suspected methicillin-resistant Staphylococcus aureus (MRSA). Which nursing intervention(s) should the nurse include in the plan of care? Select all that apply.

Correct Answer is ["C","D","E"]

Explanation

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Correct Answer is D

Explanation

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