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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Jerking contractions of the head and neck is more indicative of seizures or other neurological conditions.
B. Pinpoint pupils can be associated with various conditions, including opioid overdose or pontine hemorrhage, but it's not specifically related to Babinski's sign.
C. Pronation of the arms is a general assessment finding, not specifically indicative of a neurological issue.
D. Dorsiflexion of the great toe is the classic response for Babinski's sign. It is an abnormal reflex indicating upper motor neuron damage.
Correct Answer is D
Explanation
A. Severe blood loss actually decreases blood volume, which leads to decreased cardiac output and ultimately lower MAP.
B. While it's true that the body initially responds to blood loss by vasoconstricting to maintain blood pressure, this compensatory mechanism can only last for so long. As blood loss continues, MAP will decrease.
C. There is no direct correlation to MAP. MAP is directly influenced by cardiac output and systemic vascular resistance (SVR). Blood volume is a major determinant of both.
D. A decrease in blood volume leads to decreased preload, which reduces cardiac output. This, in turn, lowers MAP.
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