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. The primary purpose of a halo fixation device is to immobilize the cervical spine to prevent further injury and promote healing.
B. The halo device provides rigid immobilization of the cervical spine.
C. This is incorrect and dangerous. The screws in the halo device should only be tightened by a healthcare professional.
D. Applying talcum powder under the halo vest can actually increase the risk of skin breakdown. The area should be kept clean and dry.

A. The drug is not given to clients who are taking anticoagulant or antiplatelet therapy. B. The drug is given in a bolus over the first 3 minutes followed by a continuous infusion. C. The recommended time for drug administration is within 90 minutes after admission to the emergency department. D. The maximum dosage of the drug, including the bolus, is 120 mg intravenously.

Correct Answer is B

Explanation

A. While there are strict inclusion and exclusion criteria for alteplase administration, this statement is overly broad. There are certain situations where anticoagulant or antiplatelet therapy can be managed to allow for alteplase use.
B. Alteplase is administered as a bolus over 1 minute, followed by an infusion over 60 minutes.
C. While time is critical in stroke treatment, the recommended window for alteplase administration is typically within 3-4.5 hours of symptom onset.
D. The maximum dose of alteplase is actually 0.9 mg/kg, up to a maximum of 90 mg.

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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 teaching the family of a client who is receiving treatment for a spinal cord injury with a halo fixation device. Which of the following statements should the nurse make?

Correct Answer is B

Explanation

The emergency department nurse is preparing an infusion of IV alteplase for a client who suffered a cerebrovascular accident (CVA). Which of the following statements is accurate about the administration of alteplase?

Correct Answer is B

Explanation

A nurse is caring for a client who reports heart palpitations that come and go. An ECG confirms the client is experiencing episodes of ventricular tachycardia (VT). The client is stable. The nurse should anticipate the need for taking which of the following actions?

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 reviewing the EKG strip of a client who has prolonged vomiting. Which of the following abnormalities on the client's EKG should the nurse interpret as a sign of hypokalemia?

A nurse is caring for a client who has a suspected diagnosis of myasthenia gravis. The provider prescribes a Tensilon test. Which of the following findings indicates a positive test?

A nurse is caring for a 73-year-old client in the emergency department (ED). Exhibits It has been identified that the client is in sepsis. Select the 4 actions that the nurse should complete in the first hour to manage sepsis and prevent further complications?

A nurse is preparing to administer acetaminophen 10 mg/kg/dose to a child who weighs 28 lb. The amount available is acetaminophen 120 mg/5 mL. How many ml should the nurse administer? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)

A nurse is caring for a client who is at risk for shock. Which of the following findings is the earliest indicator that this complication is developing?

A nurse is caring for a client who has had a stroke. Exhibits Select the 3 findings that require immediate follow-up.