Nokea
The nurse is evaluating the progress of a completely paraplegic female client with a C6-C7 spinal cord injury. Which indicator signifies that the client is improving in physical therapy?
- A. The client can control the motorized wheelchair.
- B. The client states she wants to stand up with assistance.
- C. The client says she wants to move her toes.
- D. The client says she regained her bladder control.
Correct Answer: A
Rationale: Controlling a motorized wheelchair indicates improved upper body function, appropriate for C6-C7 injury.
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The nurse is caring for a client who is paraplegic secondary to a spinal cord injury. While planning this client's discharge, which would be most appropriate to include in the client's plan of care?
- A. The client and their family members will arrange for rehabilitation.
- B. The rehabilitation plan should be implemented early in the client's treatment.
- C. The client should plan for minimal and short-term rehabilitation, as they will return to their former activities.
- D. Long-term care should be arranged, as the client can no longer perform self-care.
Correct Answer: B
Rationale: Early rehabilitation is critical for optimizing recovery and adaptation in spinal cord injury patients.
The nurse is assessing a client with suspected neurogenic shock. Which of the following findings would support a diagnosis of neurogenic shock?
- A. Respiratory acidosis
- B. Thready peripheral pulses
- C. Diaphoresis
- D. Polyuria
Correct Answer: C
Rationale: Diaphoresis is a sign of neurogenic shock due to loss of sympathetic tone.
A nurse is caring for a client on bed rest following a spinal cord injury. When positioning the client's feet, which position would prevent the client from developing foot drop?
- A. Supination
- B. Dorsiflexion
- C. Hyperextension
- D. Abduction
Correct Answer: B
Rationale: Dorsiflexion prevents foot drop by maintaining proper foot alignment.
The following scenario applies to the next 1 items
The nurse cares for a 75-year-old client who arrives at the emergency department
Item 1 of 1
History And Physical
Vital Signs
1900: The client arrives with left facial droop, inability to move her left arm and leg, and expressive aphasia. According to the husband, they were out eating dinner, and the symptoms started suddenly, and she fell to the ground. The symptoms started 45 minutes prior to arrival at the ED. Past medical history includes atrial fibrillation, hypertension, diabetes mellitus, and hyperlipidemia.
Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, two (2) actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client's progress: Condition
- A. Transport the client for computed tomography (CT) scan
- B. Obtain laboratory work (PT, INR, aPTT, troponin, CBC, CMP, Capillary Blood glucose)
- C. Complex Migraine
- D. Severe Hypoglycemia
- E. Cerebral Vascular Accident
- F. Vital Signs
- G. Glasgow Coma Scale (GCS)
Correct Answer: A,B,E,F,G
Rationale: Symptoms (facial droop, hemiparesis, aphasia) indicate a stroke (CVA). CT scan and lab work are critical for stroke diagnosis and thrombolytic eligibility. GCS and vital signs monitor neurological and hemodynamic status in stroke.
A client is admitted with a possible diagnosis of Guillain-Barré syndrome. Which important question should the nurse include when taking this client's history?
- A. Do you experience frequent bruising?'
- B. Did you have a recent respiratory or gastrointestinal infection?'
- C. Have you been overseas during the past four months?'
- D. Has anybody in your family had Guillain-Barré syndrome?'
Correct Answer: B
Rationale: Recent infections are a common trigger for Guillain-Barré syndrome.