When classifying spinal cord injuries, which of the following does the nurse understand is an example of the level of injury?
Quadriplegia
Incomplete loss of function
CA injury
Hyperextension
The Correct Answer is C
Choice A Rationale: Quadriplegia is a type of paralysis that affects all four limbs and the trunk, usually caused by an injury to the cervical spine (C1-C8).
Choice B Rationale: Incomplete loss of function refers to the extent of injury and whether some neurological function remains, not the level of injury.
Choice C Rationale: CA injury refers to cervical spine injury, which is the most common level of spinal cord injury.
Choice D Rationale: Hyperextension, like other mechanisms of injury (such as compression, flexion, or flexion-rotation), can contribute to spinal cord injury but does not define the level of injury.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A Rationale: Cleansing the wound may be necessary, but the priority in this case is to assess for any retained foreign bodies, such as the nail, and potential structural damage, which can be done through an X-ray.
Choice B Rationale: The client's immunization history is not the priority when assessing and managing a wound like this.
Choice C Rationale: Dressing the wound may be necessary but should come after assessing for retained foreign bodies and potential structural damage.
Choice D Rationale: Requesting an X-ray is the priority action because it helps determine if the nail is still present and if there is any damage to deeper structures, such as bones or foreign body remnants.
Correct Answer is A
Explanation
Choice A Rationale: Keeping window blinds open during the day is a non pharmacological approach to help regulate the patient's circadian rhythm and may reduce the severity of sundowning, a common phenomenon in dementia.
Choice B Rationale: Having the patient take a mid-morning nap may disrupt the patient's sleep-wake cycle and worsen sundowning.
Choice C Rationale: Providing hourly orientation to time and place may be overwhelming for the patient and not necessarily effective in addressing sundowning.
Choice D Rationale: Moving the patient to a quiet room in the afternoon may not address the underlying issue of sundowning and may not be practical in a long-term care setting.
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