Exhibits

A nurse is providing discharge teaching. Which of the following client statements indicate an understanding of the teaching?
Client Statements

"I will look up at the ceiling when I swallow."

"I will have to stop watching television while I eat."

"My food will have to be the consistency of pudding."

"I can have cream soups on this diet."

"I shouldn't drink liquids while I have food in my mouth."

"I won't be able to eat nuts anymore."

Answer and Explanation

Correct Answer : B,C,E,F

A.   "I will look up at the ceiling when I swallow.". The recommended position for swallowing is typically sitting upright with the chin slightly tucked.
B.   "I will have to stop watching television while I eat." This indicates an understanding of the importance of focusing on eating and avoiding distractions.
C.   "My food will have to be the consistency of pudding." This indicates understanding of the Level 3 dysphagia diet, which requires foods to be moist and easily swallowed.
D.   "I can have cream soups on this diet." While cream soups might seem like a good option, they can be too thick for a Level 3 dysphagia diet. The consistency should be more like a thin purée.
E.   "I shouldn't drink liquids while I have food in my mouth." This demonstrates understanding of the importance of avoiding choking hazards.
F.   "I won't be able to eat nuts anymore." This indicates understanding of the restrictions on hard, crunchy foods on a Level 3 dysphagia diet.

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Correct Answer is C

Explanation

A. This client is at risk for other complications such as electrolyte imbalances or heart failure, but not specifically neurogenic shock.
B. This client is experiencing respiratory distress, which is a different type of shock (anaphylactic or septic shock might be considered, but not neurogenic).

C. Guillain-Barré syndrome is an autoimmune disorder that affects the nervous system, often leading to paralysis. It can cause a rapid loss of muscle function, which can result in neurogenic shock due to loss of sympathetic nervous system tone.
D. This client is at risk for hypovolemic shock due to fluid loss, not neurogenic shock.

A. Ability to self-feed with the use of adaptive equipment B. Ability to achieve independent transfer from bed to wheelchair C. Use of a wheelchair with a chin or mouth stick D. Independent control of bowel and bladder function

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.

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Exhibits A nurse is providing discharge teaching. Which of the following client statements indicate an understanding of the teaching? Client Statements

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is providing care for a group of clients in the emergency department. Which of the following clients is at risk for developing neurogenic shock?

Correct Answer is C

Explanation

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

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Exhibits

A nurse is providing discharge teaching. Which of the following client statements indicate an understanding of the teaching?
Client Statements