On admission to the emergency department, a patient with a C5 compression fracture can move only his head and has flaccid paralysis of all extremities. The distraught family asks if the paralysis is permanent. Which is the best response by the nurse?

"It is too early to tell. When the spinal shock subsides, we will know more."

"You should talk to your physician about things of that nature."

"No. Significant recovery of function should occur in a few days."

"Yes. In all likelihood, the paralysis is probably permanent."

Answer and Explanation

The Correct Answer is A

A. "It is too early to tell. When the spinal shock subsides, we will know more."

This response is appropriate. Spinal shock can initially obscure the extent of neurological injury, and it may take time for the full extent of the injury to become apparent. By acknowledging this and suggesting that more information will be available once spinal shock subsides, the nurse provides a realistic perspective without prematurely predicting the outcome.

B. "You should talk to your physician about things of that nature."

This response may come across as dismissive or evasive. While it is true that the physician ultimately determines the patient's prognosis, the family may be seeking reassurance and guidance from the nurse as well.

C. "No. Significant recovery of function should occur in a few days."

This response is overly optimistic and potentially misleading. While some improvement may occur in the days following a spinal cord injury, significant recovery of function within a few days is unlikely, especially in cases of flaccid paralysis of all extremities.

D. "Yes. In all likelihood, the paralysis is probably permanent."

This response is overly pessimistic and lacks sensitivity. It may unnecessarily distress the family and extinguish hope for the patient's recovery.

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Correct Answer is ["15"]

Explanation

To calculate the dose of amantadine for a client with parkinsonism, the nurse needs to use the following formula:

Dose (mL) = Ordered dose (mg) / Concentration (mg/mL).

In this case, the ordered dose is 150 mg and the concentration is 50 mg/5 mL. Therefore, the dose in mL is:

Dose (mL) = 150 mg / (50 mg/5 mL)

Dose (mL) = 150 mg x (5 mL/50 mg)

Dose (mL) = 15 mL

The nurse should round the answer to the nearest whole number, which is 15 mL. The nurse should administer 15 mL of amantadine oral solution to the client.

A. "Have you had an MMR immunization?" B. "Have you had a recent upper respiratory infection?" C. "Have you traveled overseas recently?" D. "Are you taking a multivitamin?"

Correct Answer is B

Explanation

A. "Have you had an MMR immunization?"

This question is not directly relevant to the assessment of Guillain-Barré syndrome. MMR immunization history may be pertinent to other health assessments, such as immunity to measles, mumps, and rubella.

B. "Have you had a recent upper respiratory infection?"

This is the correct answer. GBS often occurs after a recent upper respiratory or gastrointestinal infection, so asking about recent illnesses can provide valuable information for diagnosis.

C. "Have you traveled overseas recently?"

While travel history may be relevant to certain infectious diseases, it is not typically associated with the development of Guillain-Barré syndrome. Therefore, this question is less pertinent in this context.

D. "Are you taking a multivitamin?"

The use of multivitamins is unlikely to be directly related to the development of Guillain-Barré syndrome. While nutritional status is important for overall health, it is not a primary focus when assessing for GBS.

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On admission to the emergency department, a patient with a C5 compression fracture can move only his head and has flaccid paralysis of all extremities. The distraught family asks if the paralysis is permanent. Which is the best response by the nurse?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is ["15"]

Explanation

A nurse is collecting data from a client who has a possible medical diagnosis of Guillain-Barré syndrome (GBS). Which of the following questions should the nurse ask the client?

Correct Answer is B

Explanation

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A nurse is caring for a client who has multiple sclerosis and reports a tightening feeling around their torso. Which of the following conditions should the nurse recognize this finding indicates?

On admission to the emergency department, a patient with a C5 compression fracture can move only his head and has flaccid paralysis of all extremities. The distraught family asks if the paralysis is permanent. Which is the best response by the nurse?

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