A nurse is preparing a care plan for a client with a spinal cord injury. Which of the following is the highest priority for the nurse to implement?

oral care

offering the client to discuss their feelings

diet modifications

application of compression stockings

Answer and Explanation

The Correct Answer is C

Choice A Rationale: Oral care is important for overall hygiene but may not take precedence over other critical aspects of care for a client with a spinal cord injury.

Choice B Rationale: Offering the client to discuss their feelings is important for emotional support but may not be the highest priority.

Choice C Rationale: Diet modifications are a high priority because they are essential for addressing the client's nutritional needs and preventing complications related to the spinal cord injury, such as pressure ulcers and infections.

Choice D Rationale: The application of compression stockings may have a role in the care plan but is not typically the highest priority for a client with a spinal cord injury.

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Correct Answer is C

Explanation

Choice A Rationale: Reporting difficulty sleeping may be important but is not typically a critical concern in Guillain-Barre Syndrome.

Choice B Rationale: Removing the sequential compression device once a shift may require clarification or education but is not a significant medical concern.

Choice C Rationale: Hypoactive bowel sounds can indicate a potential bowel obstruction or paralytic ileus, which is a significant medical concern in clients with Guillain-Barre Syndrome and should be reported to the physician.

Choice D Rationale: A Glasgow Coma Score of 15 is within the normal range and would not typically require reporting to the physician in the context of Guillain-Barre Syndrome.

A. A hypertension B. B rapidly elevating temperature C. C bradycardia D. D fixed and dilated pupils E. E hypotension

Correct Answer is ["C","E"]

Explanation

Choice A Rationale: Hypertension is not a sign of neurogenic shock, but rather of autonomic dysreflexia, a life-threatening condition that can occur in patients with spinal cord injury above T6.

Choice B Rationale: Rapidly elevating temperature is also a sign of autonomic dysreflexia, not neurogenic shock. Neurogenic shock can cause hypothermia due to impaired thermoregulation.

Choice C Rationale: Bradycardia is a sign of neurogenic shock due to the loss of sympathetic stimulation to the heart, which normally increases the heart rate and contractility.

Choice D Rationale: Fixed and dilated pupils are a sign of brain death, not neurogenic shock. Neurogenic shock can cause miosis (constriction of the pupils) due to unopposed parasympathetic stimulation.

Choice E Rationale: Hypotension is a sign of neurogenic shock due to the vasodilation and decreased venous return caused by the loss of sympathetic tone.

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A nurse is preparing a care plan for a client with a spinal cord injury. Which of the following is the highest priority for the nurse to implement?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

When planning care for a client hospitalized with Guillain-Barre Syndrome, which of the following will the nurse report to the physician?

Correct Answer is C

Explanation

A client has sustained a T4-T5 injury and the nurse suspects he is in neurogenic shock. Which of the following manifestations are consistent with neurogenic shock? Select All that Apply

Correct Answer is ["C","E"]

Explanation

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