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 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.

A. Educate about the importance of proper food handling B. Offer food at least 4 times a day C. Anticipate administration of opioids D. Provide distraction activities

Correct Answer is C

Explanation

Choice A Rationale: Educating about the importance of proper food handling is important for preventing foodborne illnesses but is not specific to the care of a client with tetanus.

Choice B Rationale: Offering food at least 4 times a day may be necessary for maintaining nutritional support, but it does not address the specific care needs of a client with tetanus.

Choice C Rationale: Anticipating administration of opioids is an important component of the care plan for tetanus. Opioids can help manage muscle spasms and severe pain associated with tetanus.

Choice D Rationale: Providing distraction activities may be beneficial for clients with tetanus to help divert their attention from muscle spasms and discomfort, but it is not the primary intervention.

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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

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

When caring for the client hospitalized with tetanus, which of the following will the nurse include in the care plan?

Correct Answer is C

Explanation

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The nurse is providing care for a client who was placed in a halo brace 2 days ago because of a spinal cord injury. Which assessment is the first priority of the nurse?

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A client arrives with respiratory muscle weakness, difficulty swallowing and abdominal pain. Which of the following reported by the client's husband is relevant to the client's manifestations?

When educating a client about tetanus, which of the following will the nurse include in teaching? Select All that Apply

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