A nurse is caring for a client who has a complete spinal cord injury. Based on the nurse's understanding about the degree of this type of injury, what can the nurse expect will be the client's level of function?
The client will need 24-hour a day care.
The client will be able to assist with transfer and perform self-care.
The client will be able to roll over independently.
The client will be able to drive an electric wheelchair.
The Correct Answer is A
Choice A Reason: This is the correct choice because a complete spinal cord injury is a condition where there is no motor or sensory function below the level of injury. The client will have paralysis of all four limbs (quadriplegia) and loss of bladder, bowel, and sexual function. The client will also have impaired thermoregulation, breathing, and blood pressure. The client will need 24-hour a day care to assist with mobility, hygiene, elimination, nutrition, and prevention of complications.
Choice B) Reason: This is incorrect because a client who is able to assist with transfer and perform self-care has a partial spinal cord injury, not a complete one. A partial spinal cord injury is a condition where there is some motor or sensory function below the level of injury. The degree of impairment depends on the extent and location of the damage.
Choice C Reason: This is incorrect because a client who is able to roll over independently has a lower spinal cord injury, not a complete one. A lower spinal cord injury is a condition where there is damage to the lumbar or sacral segments of the spinal cord. The client will have paralysis of the lower limbs (paraplegia) and some loss of bladder, bowel, and sexual function. The client will still have some control over the upper limbs and trunk.
Choice D Reason: This is incorrect because a client who is able to drive an electric wheelchair has an upper spinal cord injury, not a complete one. An upper spinal cord injury is a condition where there is damage to the cervical or thoracic segments of the spinal cord. The client will have paralysis of all four limbs (quadriplegia) and loss of bladder, bowel, and sexual function. However, the client may still have some movement or sensation in the shoulders, arms, or hands.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A Reason: This is the correct choice because a complete spinal cord injury is a condition where there is no motor or sensory function below the level of injury. The client will have paralysis of all four limbs (quadriplegia) and loss of bladder, bowel, and sexual function. The client will also have impaired thermoregulation, breathing, and blood pressure. The client will need 24-hour a day care to assist with mobility, hygiene, elimination, nutrition, and prevention of complications.
Choice B) Reason: This is incorrect because a client who is able to assist with transfer and perform self-care has a partial spinal cord injury, not a complete one. A partial spinal cord injury is a condition where there is some motor or sensory function below the level of injury. The degree of impairment depends on the extent and location of the damage.
Choice C Reason: This is incorrect because a client who is able to roll over independently has a lower spinal cord injury, not a complete one. A lower spinal cord injury is a condition where there is damage to the lumbar or sacral segments of the spinal cord. The client will have paralysis of the lower limbs (paraplegia) and some loss of bladder, bowel, and sexual function. The client will still have some control over the upper limbs and trunk.
Choice D Reason: This is incorrect because a client who is able to drive an electric wheelchair has an upper spinal cord injury, not a complete one. An upper spinal cord injury is a condition where there is damage to the cervical or thoracic segments of the spinal cord. The client will have paralysis of all four limbs (quadriplegia) and loss of bladder, bowel, and sexual function. However, the client may still have some movement or sensation in the shoulders, arms, or hands.
Correct Answer is D
Explanation
Choice A Reason: A heart rate of 122/min is elevated, but not life-threatening. It could be due to pain, anxiety, dehydration, or infection.
Choice B Reason: A urinary output of 25 ml/hr is low, but not critical. It could indicate fluid loss, kidney damage, or inadequate fluid resuscitation.
Choice C Reason: A pain level of 6 on a scale of 0 to 10 is moderate, but not severe. It could be managed with analgesics and non-pharmacological interventions.
Choice D Reason: This is the correct answer because difficulty swallowing can indicate airway obstruction, inhalation injury, or edema of the throat. It can compromise breathing and require immediate intervention.
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