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 B

Explanation

A. Insert a padded tongue blade into the client's mouth.

This intervention is not recommended. Placing any object, including a padded tongue blade, into the mouth of someone experiencing a seizure poses a risk of injury, such as biting the tongue or breaking teeth. It can also obstruct the airway and increase the risk of aspiration. Therefore, inserting anything into the client's mouth during a seizure is contraindicated.

B. Place a pillow under the client's head.

Placing a pillow under the client's head can help prevent head injury by providing cushioning and support. It can also help maintain the client's airway and reduce the risk of aspiration. Therefore, this intervention is appropriate and helps ensure the client's safety during the seizure.

C. Gently restrain the client's extremities.

Restraining the client's extremities is not recommended during a seizure. It can increase the risk of injury, such as fractures or dislocations, and may exacerbate muscle contractions. It's important to allow the client's movements to occur naturally while taking measures to ensure their safety, such as removing nearby objects and providing a safe environment.

D. Keep the client in a supine position.

It is essential to ensure that the client's head is turned to the side (recovery position) to prevent aspiration and allow for drainage of oral secretions. Additionally, the nurse should remove any nearby objects that could pose a risk of injury during the seizure.

A. A continuous seizure state in which seizures occur in rapid succession B. A sensory warning that a seizure is imminent C. A period of sleepiness following the seizure during which arousal is difficult D. A brief loss of consciousness accompanied by staring

Correct Answer is B

Explanation

A. A continuous seizure state in which seizures occur in rapid succession:

This describes status epilepticus, a medical emergency characterized by prolonged or continuous seizures. It is not related to the concept of an aura.

B. A sensory warning that a seizure is imminent:

This is the correct answer. An aura is a subjective sensation or symptom that acts as a warning sign that a seizure is about to occur. Auras can vary widely among individuals and may include visual, auditory, olfactory, or other sensory experiences.

C. A period of sleepiness following the seizure during which arousal is difficult:

This describes the postictal state, which occurs after a seizure. During this period, the individual may experience confusion, drowsiness, or difficulty arousing from sleep. It is not specifically related to the concept of an aura.

D. A brief loss of consciousness accompanied by staring:

This describes an absence seizure, characterized by a brief loss of awareness and a blank stare. Absence seizures typically do not have an aura preceding them.

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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?

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Explanation

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