When caring for a client with a cervical spinal cord injury, which intervention is the most important for the nurse to implement?

Assess the extremity reflexes.

Logroll to change positions.

Immobilize the head in anatomical alignment.

Obtain hourly neurological assessments.

Answer and Explanation

The Correct Answer is C

Choice A reason: Assessing the extremity reflexes is important for evaluating neurological function but is not the immediate priority.

Choice B reason: Logrolling to change positions is a technique used to maintain spinal alignment, but it is not the first intervention to ensure immediate safety.

Choice C reason:

The correct answer is c) because immobilizing the head in anatomical alignment is crucial to prevent further injury to the spinal cord. Proper immobilization helps stabilize the cervical spine and protects the spinal cord from additional damage.

Choice D reason: Obtaining hourly neurological assessments is important for monitoring the client's condition but comes after ensuring the cervical spine is properly immobilized.

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Correct Answer is D

Explanation

Choice A reason: Hematuria is expected after lithotripsy and should be monitored, but it is not the most critical instruction.

Choice B reason: Using an incentive spirometer is important for respiratory care but not specific to lithotripsy.

Choice C reason: Restricting physical activities is not necessary unless advised by the healthcare provider.

Choice D reason:

The correct answer is d) because monitoring the urinary stream for a decrease in output is crucial to detect any complications such as obstruction or infection after lithotripsy.

A. Sleep flat in a supine position. B. Observe pupil response of the right eye. C. Turn, cough, and deep breathe every 2 hours. D. Administer a stool softener.

Correct Answer is D

Explanation

Choice A reason: Sleeping flat in a supine position may increase intraocular pressure.

Choice B reason: Observing the pupil response of the right eye is not relevant to the left eye procedure.

Choice C reason: Turning, coughing, and deep breathing are important post-surgery but not specific to cataract extraction.

Choice D reason:

The correct answer is d) because administering a stool softener helps prevent straining during bowel movements, which can increase intraocular pressure.

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When caring for a client with a cervical spinal cord injury, which intervention is the most important for the nurse to implement?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client with urolithiasis is preparing for discharge after lithotripsy. Which intervention should the nurse include in the client's postoperative discharge instructions?

Correct Answer is D

Explanation

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Correct Answer is D

Explanation

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