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 correct because the patient's Glasgow Coma Scale score is 9. The Glasgow Coma Scale is a tool that assesses the level of consciousness of a patient with a head injury by measuring three parameters: eye opening, verbal response, and motor response. The patient's eye opening score is 3 (opens eyes to verbal command), verbal response score is 4 (confused speech), and motor response score is 2 (withdraws from pain). The total score is the sum of these three scores, which is 9.
Choice B Reason: This is incorrect because the patient's Glasgow Coma Scale score is not 11. To get a score of 11, the patient would need to have a higher motor response score, such as 4 (withdraws to touch) or 5 (localizes to pain).
Choice C Reason: This is incorrect because the patient's Glasgow Coma Scale score is not 15. To get a score of 15, the patient would need to have the highest scores for all three parameters, such as 4 (opens eyes spontaneously), 5 (oriented speech), and 6 (obeys commands).
Choice D Reason: This is incorrect because the patient's Glasgow Coma Scale score is not 13. To get a score of 13, the patient would need to have a higher verbal response score, such as 5 (oriented speech).
Correct Answer is ["A","B","C"]
Explanation
Choice A Reason: This is a correct choice. Trying to avoid scratching is an advice that the nurse will provide to the client, as it prevents further damage and infection of the skin. Scratching can break the skin barrier and introduce bacteria or fungi into the wound, leading to inflammation and complications.
Choice B Reason: This is a correct choice. Applying a moist cool compress is an advice that the nurse will provide to the client, as it soothes and relieves itching and swelling. A moist cool compress can reduce inflammation and histamine release, which are responsible for allergic symptoms.
Choice C Reason: This is an incorrect choice. Using alcohol to cleanse the area is not an advice that the nurse will provide to the client, as it irritates and dries out the skin. Alcohol can strip away the natural oils and moisture from the skin, making it more prone to cracking and itching.
Choice D Reason: This is an incorrect choice. Using a wooden stick to scratch lesions is not an advice that the nurse will provide to the client, as it causes more harm than good. A wooden stick can injure or infect the skin, as well as spread the allergen or irritant to other areas.
Choice E Reason: This is a correct choice. Avoiding hot air is an advice that the nurse will provide to the client, as it aggravates itching and inflammation. Hot air can increase blood flow and histamine release, which are responsible for allergic symptoms. The client should also avoid hot water or showers, as they can have the same effect.
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