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. Fresh fish

Fresh fish does not contain significant amounts of tyramine. Therefore, there is no need to eliminate fresh fish from the client's diet due to its interaction with selegiline.

B. Cheddar cheese

This is the correct answer. Cheddar cheese is a high-tyramine food and should be eliminated from the client's diet when taking MAOIs. Aged cheeses, such as cheddar, contain high levels of tyramine due to the fermentation process, which can increase the risk of a hypertensive crisis when combined with MAOIs.

C. Cherries

Cherries do not contain significant amounts of tyramine. Therefore, there is no need to eliminate cherries from the client's diet due to their interaction with selegiline.

D. Chicken

Chicken does not contain significant amounts of tyramine. Therefore, there is no need to eliminate chicken from the client's diet due to its interaction with selegiline.

A. "Incorporate nonverbal cues in the conversation." B. "Ask multiple choice questions as part of the conversation." C. "Use a higher-pitched tone of voice when speaking." D. "Use simple child-like statements when speaking."

Correct Answer is A

Explanation

A. "Incorporate nonverbal cues in the conversation."

This is an appropriate response. Nonverbal cues, such as gestures, facial expressions, and body language, can help convey meaning and support comprehension for individuals with aphasia. Using visual aids or pointing to objects can also enhance communication.

B. "Ask multiple choice questions as part of the conversation."

While multiple choice questions can be helpful in some situations, they may not always be appropriate for individuals with aphasia. It's important to assess the client's specific communication needs and preferences. Open-ended questions and simple, direct language may be more effective for facilitating communication.

C. "Use a higher-pitched tone of voice when speaking."

Altering the tone of voice may not necessarily improve communication for individuals with aphasia. Instead, it's important to speak in a clear, natural tone at a moderate pace. Speaking too loudly or using a higher-pitched voice may be perceived as patronizing or condescending.

D. "Use simple child-like statements when speaking."

While it's important to use simple and clear language, using child-like statements may be inappropriate and demeaning to the client. Respectful communication that acknowledges the individual's intelligence and dignity is essential. Simplify language and sentences as needed, but avoid speaking down to the client.

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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

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Correct Answer is B

Explanation

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Correct Answer is A

Explanation

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