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."
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["15"]
Explanation
To calculate the dose of phenytoin suspension, the nurse should use the following formula:
Dose (mL) = Desired dose (mg) / Concentration (mg/mL) x Volume (mL)
Plugging in the values from the question, we get:
Dose (mL) = 75 mg / (25 mg/5 mL) x 5 mL
Dose (mL) = 15 mL
Therefore, the nurse should administer 15 mL of phenytoin suspension to the patient
Correct Answer is A
Explanation
A. Toes turning up and spreading:
This description corresponds to the abnormal finding in the Babinski reflex. In a positive Babinski sign, the big toe (hallux) dorsiflexes (turns upward) and the other toes fan out. This response is abnormal in adults but normal in infants up to a certain age.
B. Downward curl of the toes:
This response is typical of the normal plantar reflex, where the toes curl downward (plantar flexion) in response to stimulation of the sole of the foot. It is not indicative of the Babinski reflex.
C. Pain in the big toe:
Pain in the big toe is not a characteristic finding of the Babinski reflex. The Babinski sign is assessed by observing the movement pattern of the toes in response to stimulation, rather than eliciting pain.
D. Big toe bending upward:
The big toe bending upward, or dorsiflexion of the big toe, is a specific component of the positive Babinski sign. However, it is typically accompanied by spreading of the other toes, which is the hallmark feature of the Babinski reflex.
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