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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A Reason:
Keeping lights turned to medium level in the evening is incorrect. This intervention is aimed at reducing environmental stimuli, which may be appropriate for some patients with neurological conditions to minimize sensory overload and promote rest. However, it is not a specific intervention for preventing cerebral aneurysm rupture.
Choice B Reason:
Maintaining the head of the bed between 30 and 45° is correct. Keeping the head of the bed elevated can help reduce intracranial pressure and decrease the risk of cerebral aneurysm rupture or rebleeding in patients with aneurysmal subarachnoid hemorrhage. This position promotes venous drainage from the brain and helps prevent increases in intracranial pressure.
Choice C Reason:
Administering hypotonic intravenous solutions is incorrect. Hypotonic intravenous solutions have a lower osmolarity than blood plasma and can lead to cerebral edema, which may exacerbate intracranial pressure and increase the risk of cerebral aneurysm rupture. Isotonic solutions, such as normal saline (0.9% NaCl) or lactated Ringer's solution, are typically preferred for fluid resuscitation and maintenance in patients at risk of cerebral aneurysm rupture.
Choice D Reason:
Reposition the client every shift is incorrect. Repositioning the client every shift helps prevent complications associated with immobility, such as pressure ulcers, pneumonia, and venous thromboembolism. While important for overall patient care, repositioning alone does not directly address the risk of cerebral aneurysm rupture.
Correct Answer is B
Explanation
Choice A Reason:
"I have signed up for an aerobics class three times a week." This statement is incorrect. Participating in aerobics classes three times a week may not be suitable for someone with spinal stenosis, as certain movements and high-impact activities common in aerobics classes can exacerbate symptoms and increase the risk of injury to the spine.
Choice B Reason:
"I ride my bicycle every day." This statement is correct. Cycling is generally considered a low-impact exercise that can be beneficial for individuals with spinal stenosis, as it helps improve cardiovascular fitness without placing excessive stress on the spine. Riding a bicycle regularly may be a suitable exercise option for this client.
Choice C Reason:
"I like to jog a half a mile every day." This statement is incorrect. Jogging involves repetitive impact and can place significant stress on the spine, which may exacerbate symptoms of spinal stenosis. It is generally not recommended for individuals with spinal stenosis due to the high-impact nature of the activity.
Choice D Reason:
"I enjoy doing circuit training once a week.": Circuit training typically involves a combination of aerobic and strength-training exercises performed in rapid succession. While some components of circuit training, such as strength training, can be beneficial for individuals with spinal stenosis, the intensity and variety of exercises in circuit training may not be suitable for everyone with this condition.
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