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 A

Explanation

A. Atrial fibrillation is consistent with the symptoms described. It causes irregular palpitations and dizziness due to the rapid and irregular ventricular rate. The significant pulse deficit can occur because the irregular rhythm may lead to intermittent weak or absent pulses. The ECG typically shows an irregular rhythm with no identifiable P waves and an irregularly irregular ventricular response.
B. Sinus bradycardia does not usually cause a rapid and irregular heart rate. It is characterized by a regular rhythm with a slow heart rate. While it can cause fatigue and dizziness, it does not typically present with an irregular rhythm or a significant pulse deficit. Therefore, it is less consistent with the symptoms described.
C. Sinus tachycardia is characterized by a rapid but regular heart rate. It does not typically present with an irregular rhythm or significant pulse deficit. While it may cause symptoms such as palpitations and

dizziness, the regular rhythm and absence of irregularity in the ECG make it less likely to be the cause of the significant irregular pulse deficit described.
D. First-degree AV block does not usually cause a rapid and irregular heart rate. It typically presents with a regular rhythm but with a prolonged PR interval. It is not typically associated with irregular palpitations or a significant pulse deficit. The symptoms described are not characteristic of first-degree AV block.

A. The client who has chronic kidney disease B. The client experiencing an asthma attack C. The client who has Guillain-Barré syndrome D. The client who has a severe burn injury

Correct Answer is C

Explanation

A. This client is at risk for other complications such as electrolyte imbalances or heart failure, but not specifically neurogenic shock.
B. This client is experiencing respiratory distress, which is a different type of shock (anaphylactic or septic shock might be considered, but not neurogenic).

C. Guillain-Barré syndrome is an autoimmune disorder that affects the nervous system, often leading to paralysis. It can cause a rapid loss of muscle function, which can result in neurogenic shock due to loss of sympathetic nervous system tone.
D. This client is at risk for hypovolemic shock due to fluid loss, not neurogenic shock.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in an urgent care center is assessing a client who reports a sudden onset of irregular palpitations, fatigue, and dizziness. The nurse finds a rapid and irregular heart rate with a significant pulse deficit. Which of the following dysrhythmias should the nurse expect to find on the ECG?

Correct Answer is A

Explanation

A nurse is providing care for a group of clients in the emergency department. Which of the following clients is at risk for developing neurogenic shock?

Correct Answer is C

Explanation

A client is experiencing decorticate posturing. Which assessment finding would the nurse expect to observe in this client?

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A nurse is teaching a client who has septic shock about the development of disseminated intravascular coagulation (DIC). Which of the following statements should the nurse make?

A nurse is preparing to administer dabigatran to a client who has atrial fibrillation. The nurse should explain that the purpose of this medication is which of the following?

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A nurse is caring for a client who develops a ventricular fibrillation rhythm. The client is unresponsive, pulseless, and apneic. Which of the following actions is the nurse's priority?

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