A nurse is developing a plan of care for a client who has a spinal fracture and complete spinal cord transection at the level of C5. Which of the following rehabilitation goals should the nurse add to the client's plan of care?

Ability to self-feed with the use of adaptive equipment

Ability to achieve independent transfer from bed to wheelchair

Use of a wheelchair with a chin or mouth stick

Independent control of bowel and bladder function

Answer and Explanation

The Correct Answer is A

A.   This is a realistic goal for a C5 injury. Patients can often develop the strength and coordination in their arms to use adaptive equipment like a mobile arm support or a built-up spoon to feed themselves.
B.   This goal is generally not achievable with a C5 injury. Independent transfers require significant lower body strength and coordination, which are completely absent in this case.
C.   This is a potential option, but it's not a rehabilitation goal. It's more of an adaptive equipment recommendation to assist with mobility and independence in tasks like operating computer or phone.

D.   This is not a realistic goal for a complete spinal cord transection at C5. Bowel and bladder function are typically impaired below the level of injury.

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Correct Answer is D

Explanation

A. The normal P-R interval ranges from 0.12 to 0.20 seconds. A P-R interval longer than 0.20 seconds is considered prolonged and may indicate a first-degree AV block.
B. The T wave represents ventricular repolarization. Normally, the T wave is upright in most leads. An inverted T wave can indicate various conditions, including ischemia, electrolyte imbalances, or other abnormalities
C. The normal QRS duration ranges from 0.06 to 0.10 seconds. A QRS duration greater than 0.10 seconds indicates a delay in ventricular conduction, which could be due to a bundle branch block or other conduction abnormalities.
D. In a normal sinus rhythm, the P wave should consistently appear before each QRS complex. This reflects proper atrial depolarization followed by ventricular depolarization. This pattern indicates that the heart's electrical impulses are originating from the sinus node and are being properly conducted through the AV node to the ventricles.

A. Administer supplemental oxygen to the client. B. Restrain the client. C. Time the duration of the seizure. D. Place a tongue depressor in the client's mouth. E. Turn the client to the side

Correct Answer is ["A","C","E"]

Explanation

A. The client is experiencing apnea and has decreased oxygen saturation, indicating a need for supplemental oxygen.
B. Restraining a client during a seizure is dangerous and can cause injury.
C. This information is crucial for determining the type of seizure and guiding treatment.
D. Placing a tongue depressor in the client's mouth can cause trauma to the teeth and mouth and should never be done.
E. Turning the client to the side helps prevent aspiration of saliva or vomit, protecting the airway.

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A nurse is developing a plan of care for a client who has a spinal fracture and complete spinal cord transection at the level of C5. Which of the following rehabilitation goals should the nurse add to the client's plan of care?

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Naxlex Comprehensive Predictor Exams

A nurse is monitoring a client who is on telemetry. Which of the following findings on the ECG strip should the nurse recognize as normal sinus rhythm?

Correct Answer is D

Explanation

Exhibits A nurse is caring for a client who has a seizure disorder. (Select all that apply.)

Correct Answer is ["A","C","E"]

Explanation

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