A nurse is doing rounds and notes a patient in the following position: How would the nurse document this finding?

Spinal cord degeneration

Decorticate posturing

Atypical hyperreflexia

Decerebrate posturing

Answer and Explanation

The Correct Answer is D

A.   Spinal cord degeneration is a general term for the deterioration of the spinal cord and doesn't specifically describe the patient's posture.
B.   Decorticate posturing is characterized by the arms flexed and adducted, with the wrists and fingers flexed. The legs are extended and adducted, with the feet plantar flexed.
C.   Atypical hyperreflexia refers to exaggerated reflexes, not a specific posture.

D.   Decerebrate posturing is characterized by the arms extended and pronated, with the wrists and fingers flexed. The legs are stiffly extended with plantar flexion.

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Correct Answer is A

Explanation

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.

A. It raises cardiac output and MAP. B. It causes vasoconstriction and increased MAP. C. There is no direct correlation to MAP. D. Lower blood volume lowers MAP.

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.

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A nurse is doing rounds and notes a patient in the following position: How would the nurse document this finding?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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?

Correct Answer is A

Explanation

A nurse who is mentoring a graduate nurse explains the correlation between severe blood loss and the effect on the client's mean arterial pressure (MAI The graduate nurse demonstrates correct understanding when he states which of the following:

Correct Answer is D

Explanation

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