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 A

Explanation

A. Lie flat:

This option involves instructing the patient to lie flat on their back without elevating their head. Lying flat helps to maintain consistent pressure in the spinal canal, reducing the likelihood of CSF leakage from the puncture site. This position is commonly recommended after a lumbar puncture to prevent or minimize the occurrence of post-lumbar puncture headaches (PLPH).

B. Lie on left side:

This option involves instructing the patient to lie on their left side. While lying on the left side may provide some relief by reducing pressure on the lumbar puncture site, it is not typically recommended immediately after the procedure to prevent PLPH. Lying flat is generally preferred to minimize changes in CSF pressure and reduce the risk of headache.

C. Stay in semi-Fowler position:

The semi-Fowler position involves elevating the head of the bed at a 30-45 degree angle. This position is not typically recommended immediately after a lumbar puncture because it may increase CSF leakage and pressure changes, potentially exacerbating the risk of developing a headache.

D. Ambulate in the room with assistance:

Ambulating shortly after a lumbar puncture is not typically recommended as it may increase the risk of developing a headache. Movement and changes in posture can exacerbate CSF leakage and pressure changes at the puncture site, leading to the development of post-lumbar puncture headaches.

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

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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

Which position should a nurse instruct a patient to assume after a lumbar puncture to prevent a headache?

Correct Answer is A

Explanation

A nurse is preparing to administer phenytoin 75 mg PO. Available is phenytoin suspension 25 mg/5 mL. How many mL should the nurse administer? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

Correct Answer is ["15"]

Explanation

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