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 B

Explanation

A. A high CVP, not a low CVP, is typically associated with fluid overload.
B. A low CVP indicates decreased fluid volume, which is characteristic of hypovolemia. This is particularly relevant to a patient with multiple traumas who may have significant blood loss.
C. While left ventricular failure can contribute to hemodynamic instability, it's not directly correlated with a low CVP.
D. This would affect the oxygenation status of the blood, rather than the overall blood volume and CVP.

A. Provide a nonskid mat to alleviate plate movement. B. Encourage the use of the wide grip utensils. C. Remind the client to look for food on the left side of the tray. D. Encourage the client to use his right hand when feeding himself.

Correct Answer is C

Explanation

A. While this is a good safety measure for any client, it doesn't address the specific issue of homonymous hemianopsia.
B. This can be helpful for clients with motor difficulties but does not address the visual impairment.
C. Since the client has a right-sided stroke and homonymous hemianopsia, they will likely miss food on the left side of their tray. Reminding them to scan that area can help prevent them from missing food.
D. While this might seem logical, it doesn't address the underlying issue of the client's visual impairment.

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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 is evaluating the central venous pressure (CVP) of a client who has sustained multiple traumas. Which of the following interpretations of a low CVP pressure should the nurse make?

Correct Answer is B

Explanation

A nurse caring for a client who had a right-sided stroke and is exhibiting homonymous hemianopsia when eating. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

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