The nurse is caring for a patient with a complete spinal cord injury at the level of C7. Which intervention would the nurse implement in order to prevent complications related to immobility?

Frequent passive range of motion

Coughing and deep breathing exercises once per shift

Turn patient every 4 hours

Ambulate patient twice per shift

Answer and Explanation

The Correct Answer is A

A. Frequent passive range of motion exercises are crucial for preventing complications of immobility, such as contractures and pressure ulcers, and to promote circulation in patients with spinal cord injuries.

B. While coughing and deep breathing exercises are important for respiratory health, they should be performed more frequently than once per shift in patients with reduced mobility to prevent respiratory complications.

C. Turning the patient every 4 hours may not be adequate to prevent pressure ulcers; typically, patients should be turned at least every 2 hours.

D. Patients with a complete spinal cord injury at C7 typically lack the ability to ambulate, making this intervention inappropriate.

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Correct Answer is D

Explanation

A. Posterior cord injury usually affects proprioception rather than causing a distinctive pattern of motor and sensory loss.

B. Anterior cord injury generally impacts motor function and temperature and pain sensation bilaterally, not in a hemisection pattern.

C. Central cord injury primarily affects motor function in the upper extremities and is not characterized by ipsilateral motor and contralateral sensory loss.

D. Brown-Sequard syndrome typically presents with motor function loss on the same (ipsilateral) side of the injury and loss of pain and temperature sensation on the opposite (contralateral) side, making this the most likely diagnosis.

A. Blood pressure B. Bladder function C. Heart rate D. Reflexes E. Respirations

Correct Answer is ["A","C","E"]

Explanation

A. Blood pressure monitoring is essential, as spinal cord injuries at high levels can cause disruptions in autonomic regulation, leading to significant blood pressure fluctuations.

B. Bladder function is impacted by spinal cord injuries; however, it is not the initial priority in an emergency setting when life-threatening complications must be managed first.

C. Heart rate is critical as high spinal cord injuries can impact cardiac function by affecting autonomic control, potentially leading to bradycardia.

D. Reflexes are often assessed in cases of spinal injury, but they are not the immediate priority when stabilizing the patient upon arrival.

E. Respirations are a priority, as a C1 spinal cord injury can compromise respiratory function, necessitating immediate assessment to ensure adequate oxygenation and airway management.

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The nurse is caring for a patient with a complete spinal cord injury at the level of C7. Which intervention would the nurse implement in order to prevent complications related to immobility?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is D

Explanation

The Emergency Department nurse is expecting a patient with a spinal cord transection at C1. Which of the following assessments take priority upon the patient's arrival? (SELECT ALL THAT APPLY)

Correct Answer is ["A","C","E"]

Explanation

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