A nurse is caring for a client who has a transection of the spinal cord at the level of cervical 7. Which of the following assessment findings should the nurse anticipate?
The client has no sensation or movement below the level of the injury.
The client has some movement but no sensation below the level of the injury.
The client has some movement and also some sensation below the level of the injury.
The client has some sensation but no movement below the level of the Injury.
The Correct Answer is A
Choice A Reason:
The client has no sensation or movement below the level of the injury is correct. This is a characteristic finding of a complete spinal cord injury, where there is total loss of sensory and motor function below the level of the injury. This pattern is often seen in injuries involving the cervical spinal cord, such as at the level of C7.
Choice B Reason:
The client has some movement but no sensation below the level of the injury is incorrect. This finding would be more indicative of an incomplete spinal cord injury, where there is partial preservation of sensory or motor function below the level of the injury. However, with a transection of the spinal cord at C7, it is less likely for the client to have retained movement below the level of injury.
Choice C Reason:
The client has some movement and also some sensation below the level of the injury is incorrect. This finding is not typically associated with a spinal cord injury at the level of C7. With a transection of the spinal cord at this level, there is typically complete loss of sensory and motor function below the level of the injury.
Choice D Reason:
The client has some sensation but no movement below the level of the injury is incorrect. This finding is more consistent with an incomplete spinal cord injury, where there may be partial preservation of sensory function but no motor function below the level of the injury. However, with a transection of the spinal cord at C7, it is less likely for the client to have retained sensation below the level of injury.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A Reason:
Decreased blood pressure is correct. Decreased blood pressure (hypotension) is the priority finding to monitor for because it is indicative of a severe allergic reaction known as anaphylaxis. Anaphylaxis is a potentially life-threatening condition that can lead to shock, organ failure, and death if not promptly treated. Hypotension in the context of an allergic reaction suggests widespread vasodilation and increased vascular permeability, resulting in a decrease in blood pressure.
Choice B Reason:
Stomach pain is incorrect. Stomach pain may indicate gastrointestinal distress or adverse effects of the antibiotic, but it is not typically as immediately life-threatening as decreased blood pressure in the context of anaphylaxis. While abdominal pain should not be ignored, it is not the priority finding when assessing for signs of anaphylaxis.
Choice C Reason:
Urticaria is incorrect. Urticaria, also known as hives, is a common allergic reaction characterized by raised, itchy welts on the skin. While urticaria can be uncomfortable and distressing, it is not immediately life-threatening. However, urticaria may be a precursor to more severe allergic reactions, such as anaphylaxis, so it is still important to monitor closely.
Choice D Reason:
Lightheadedness is incorrect. Lightheadedness may occur as a result of hypotension in the context of anaphylaxis, but it is not as critical as directly monitoring blood pressure. Lightheadedness may also be caused by other factors, such as anxiety or dehydration, and may not always indicate a severe allergic reaction. While it is important to assess for lightheadedness and monitor the client's overall condition, it is not the priority finding compared to decreased blood pressure.
Correct Answer is D
Explanation
"If you have a cerebral aneurysm, you would be having seizures. “is incorrect because not all cerebral aneurysms cause seizures. Seizures may occur if the aneurysm ruptures and causes bleeding into the brain, but they are not a universal symptom of an unruptured cerebral aneurysm.
Choice B Reason:
"If you have a cerebral aneurysm, you will experience nausea and vomiting. “is incorrect because while headaches, nausea, and vomiting can occur with a ruptured cerebral aneurysm (subarachnoid hemorrhage), they are not necessarily present in all cases, especially with unruptured aneurysms.
Choice C Reason:
"If you had a cerebral aneurysm, you would have a stiff neck." is incorrect because a stiff neck (meningeal irritation) is typically associated with subarachnoid hemorrhage from a ruptured cerebral aneurysm, but it is not always present and is not a definitive symptom of an unruptured aneurysm.
Choice D Reason:
"If you have a cerebral aneurysm, you typically will have no symptoms." Cerebral aneurysms can vary greatly in terms of their presentation and symptoms. While some aneurysms may cause symptoms such as headaches, nausea, vomiting, seizures, or a stiff neck, many cerebral aneurysms are asymptomatic and go unnoticed until they rupture or are incidentally discovered during imaging studies for other reasons.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.