The nurse is assessing a 28-year-old client who sustained a spinal injury after diving into a shallow pool. Which finding would indicate that the client has a C-1 to C-2 injury?

The client is able to sit erect without assistance

The client is able to move fingers slightly

The client is displaying shallow respirations

The client is able to speak in full sentences

Answer and Explanation

The Correct Answer is C

A. The client is able to sit erect without assistance: This suggests a lower level injury, likely below C-2, as higher injuries often result in paralysis of respiratory muscles.

B. The client is able to move fingers slightly: This would be indicative of a higher level injury, but C-1 to C-2 injuries typically result in complete paralysis below the neck.

C. The client is displaying shallow respirations: Injuries at the C-1 or C-2 level can affect the diaphragm and the ability to breathe deeply, leading to shallow respirations.

D. The client is able to speak in full sentences: A C-1 to C-2 injury would likely affect the ability to speak, as it could impair the phrenic nerve and respiratory muscles needed for adequate breathing and speech.

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Correct Answer is D

Explanation

A. Elevated serum calcium levels: This is not typical for Paget's disease. While hypercalcemia can occur in advanced stages, the primary issue in Paget's disease is abnormal bone remodeling.

B. Elongated trunk: This is not characteristic of Paget's disease. Paget's disease affects bone remodeling and can lead to deformities such as bowing of the legs or enlarged bones, but not an elongated trunk.

C. Warm, swollen areas over femur: This can occur in Paget's disease due to increased blood flow to the affected bones, but it is not the most distinctive feature.

D. Mosaic pattern of bone: This pattern, which appears on X-ray, is a hallmark of Paget’s disease, indicating disorganized bone remodeling and a disruption of normal bone architecture.

A. Compartment syndrome B. Muscle wasting C. Skin breakdown D. Joint Stiffness

Correct Answer is A

Explanation

A. Compartment syndrome. The client’s unrelieved pain, despite analgesics, and the presence of swelling distal to the cast are warning signs of compartment syndrome. This is a medical emergency that occurs when increased pressure within a closed muscle compartment reduces blood flow, leading to tissue damage and pain.

B. Muscle wasting. Muscle wasting typically occurs over time due to disuse and is not a sudden, acute complication like compartment syndrome.

C. Skin breakdown. Skin breakdown could occur from improper cast fitting or prolonged pressure, but it would not cause unrelieved pain in the same way as compartment syndrome.

D. Joint stiffness. Joint stiffness can occur in casted limbs after removal, but it is not an acute complication like compartment syndrome.

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The nurse is assessing a 28-year-old client who sustained a spinal injury after diving into a shallow pool. Which finding would indicate that the client has a C-1 to C-2 injury?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is assessing a client with Paget's disease. Which finding would the nurse identify as being characteristic of this disease?

Correct Answer is D

Explanation

Correct Answer is A

Explanation

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