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 C
Explanation
Choice A Rationale: Urinary output is also an important assessment in clients with a C3 spinal cord injury because it helps monitor for urinary retention and potential complications but it is not a priority compared to assessing the respiratory function of this client.
Choice B Rationale: Blood pressure is important to monitor but may not be the top priority assessment in this context.
Choice C Rationale: The nurse should prioritize counting respirations for a client with a C3 spinal cord injury, as this level of injury affects the phrenic nerve that innervates the diaphragm. The client may have difficulty breathing and require mechanical ventilation.
Choice D Rationale: Bowel sounds are important but may not be the priority assessment in this case.
Correct Answer is B
Explanation
Choice A Rationale: Keeping the client NPO until fitted for a halo vest is not a standard practice, and nutritional support should be initiated as soon as possible.
Choice B Rationale: A high-calorie, high-protein diet is typically started within 3 days of a spinal cord injury to support healing and prevent muscle wasting.
Choice C Rationale: High fiber and decreased protein are not the immediate dietary needs after a spinal cord injury. High protein intake is important for tissue repair.
Choice D Rationale: Low fiber and no protein would not be recommended 2 days after a spinal cord injury, as protein intake is crucial for healing and recovery.
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