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 C
Explanation
Choice A Reason: This choice is incorrect. Inability to perform within normal limits is a vague and general term that does not describe the specific finding of left facial droop. The nurse should document the exact observation and compare it to the expected or normal range.
Choice B Reason: This choice is incorrect. Symmetrical findings mean that both sides of the body or face are equal or similar in appearance or function. Left facial droop indicates that one side of the face is lower or weaker than the other, which is not symmetrical.
Choice C Reason: This is the correct choice. Asymmetrical findings mean that both sides of the body or face are unequal or different in appearance or function. Left facial droop indicates that one side of the face is lower or weaker than the other, which is asymmetrical.
Choice D Reason: This choice is incorrect. Bilateral strength present means that both sides of the body or face have normal or adequate muscle power or force. Left facial droop indicates that one side of the face has reduced or impaired muscle power or force, which is not bilateral strength present.
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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