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. Widening pulse pressure is typically associated with increased cardiac output, which is opposite to what happens in hypovolemic shock.
B. Pulse oximetry 96% is a normal oxygen saturation level and does not indicate shock.
C. Increased deep tendon reflexes is not a typical finding in hypovolemic shock.
D. Increased heart rate is a classic compensatory mechanism in response to decreased blood volume. The body tries to maintain blood pressure by increasing heart rate.

A. Restrain the child's arms. B. Use a padded tongue blade. C. Position the child laterally. D. Attempt to stop the seizure.

Correct Answer is C

Explanation

A. Restraining the child's arms during a seizure is not recommended. Trying to hold or restrain a child’s movements can lead to injury for both the child and the caregiver. During a seizure, it is more important to ensure the child is in a safe environment and avoid any actions that might exacerbate the situation or cause harm.
B. Using a padded tongue blade is an outdated practice and is not recommended. This method was once thought to prevent the child from biting their tongue or injuring their mouth, but it can actually lead to broken teeth, injuries to the mouth, or cause airway obstruction. Instead, focusing on ensuring the child's safety and protecting their airway is more appropriate.
C. Positioning the child laterally (on their side) is an appropriate and recommended action during a seizure. This position helps keep the airway open and allows any fluids, such as saliva, to drain out of the mouth, which helps prevent aspiration and choking. This position is especially important if the child is at risk for vomiting or if the seizure lasts for a prolonged period.
D. Attempting to stop the seizure is not possible and is not recommended. Seizures typically resolve on their own, and trying to intervene actively can cause harm. Instead, focus on protecting the child from injury, monitoring the duration of the seizure, and providing support once the seizure is over.

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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 the emergency department is assessing a client who has internal injuries from a car crash. The client is disoriented to time and place, diaphoretic, and his lips are cyanotic. The nurse should anticipate which of the findings as an indication of hypovolemic shock?

Correct Answer is D

Explanation

A nurse is caring for a child who is experiencing a seizure. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

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