Which of the following manifestations can the nurse expect in a client with upper motor neuron deficit related to a spinal cord injury?

A leakage

B anuria

C flaccid bladder, inability to voluntarily void

D spastic, involuntary voiding

Answer and Explanation

The Correct Answer is D

Choice A Rationale: Leakage is not typically associated with upper motor neuron deficits related to a spinal cord injury.

Choice B Rationale: Anuria (absence of urine production) is not a common manifestation of upper motor neuron deficits in this context.

Choice C Rationale: A flaccid bladder and an inability to voluntarily void are more characteristic of lower motor neuron deficits. Upper motor neuron deficits often lead to spasticity and involuntary voiding.

Choice D Rationale: Spasticity and involuntary voiding are common manifestations of upper motor neuron deficits related to spinal cord injury. This is due to the loss of inhibitory control over reflexes, including the micturition reflex.

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Correct Answer is A

Explanation

Choice A Rationale: The purpose of a halo fixation device is to immobilize the cervical spine and prevent movement, which is crucial for healing and preventing further spinal cord injury.

Choice B Rationale: A halo fixation device does not allow for neck movement during the healing process.

Choice C Rationale: Applying talcum powder under the vest may increase the risk of skin irritation or infection.

Choice D Rationale: Turning the screws on the device should only be done by qualified healthcare professionals, not by the family.

A. A Anticipate intubation B. B Ask client to cough, then inhale and exhale deeply C. C Insert an intravenous catheter D. D Administer antihypertensives

Correct Answer is B

Explanation

Choice A Rationale: Anticipating intubation is not warranted solely based on an O2 saturation of 92% and without further assessment.

Choice B Rationale: Asking the client to cough, then inhale and exhale deeply is an appropriate initial action to improve oxygenation and assess the client's respiratory status.

Choice C Rationale: Inserting an intravenous catheter is unrelated to the client's O2 saturation and would not address the immediate concern.

Choice D Rationale: Administering antihypertensives is not indicated based on the O2 saturation level, and it may not be safe without further assessment.

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Which of the following manifestations can the nurse expect in a client with upper motor neuron deficit related to a spinal cord injury?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is teaching the family of a client who is receiving treatment for a spinal cord injury with a halo fixation device. Which of the following statements should the nurse make?

Correct Answer is A

Explanation

After assessing a client with deficits from a spinal cord injury, the nurse identifies the client's 02 saturation is 92%. Which of the following is the best first action by the nurse?

Correct Answer is B

Explanation

A client with a new diagnosis of trigeminal neuralgia is receiving education to prevent triggering an acute onset. Which of the following will the nurse include in teaching?

A client who suffered partial paralysis is repositioned by the nurse every 2 hours. After placing the client in a side-lying position, what action will nurse take to prevent complications?

After performing an assessment on a client with a spinal cord injury, which intervention will the nurse employ to prevent cardiovascular complications?

A nurse is teaching the family of an older adult client who has a new diagnosis of dementia. Which of the following statements should the nurse include in the teaching?

The nurse caring for the client with Alzheimer's documents that the client is in the early stage of Alzheimer's. Which findings are consistent with mild Alzheimer's disease?

A home health nurse is caring for a client who is quadriplegic following a spinal cord injury and who is adjusting to the home environment. Which of the following client statements indicate the client is adapting?

A client with Alzheimer's is having increased behavioral issues that have become a safety concern for the client and others. Which of the following medications will the nurse discuss with the physician for inclusion in the client's care plan?

A nurse is offering teaching to a caregiver about urinary system complications that occur as a result of spinal cord injury. Which of the following will the nurse include in teaching?