A 22-year old patient involved in a motorcycle accident has a complete transection of the spinal cord at T-8 resulting in paraplegia. Nursing interventions includes repositioning the patient every 1-2 hours to:
Improve venous circulation and prevent VTE formation
Prevent flexion and contractures of the extremities
Decrease the development of a paralytic ileus
Prevent the development of pressure ulcers
The Correct Answer is D
A. Improve venous circulation and prevent VTE formation. – Incorrect. While repositioning does help with circulation, it is primarily done to prevent pressure injuries.
B. Prevent flexion and contractures of the extremities. – Incorrect. Contracture prevention is important, but passive ROM exercises are more effective for this purpose.
C. Decrease the development of a paralytic ileus. – Incorrect. Paralytic ileus is managed through bowel programs and early mobility, not repositioning alone.
D. Prevent the development of pressure ulcers. – Correct Answer. Paralyzed patients are at high risk for pressure ulcers, especially over bony prominences like the sacrum. Repositioning reduces prolonged pressure, which can lead to skin breakdown.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Bradycardia is not a typical sign of hypoglycemia; tachycardia is more common.
B. A fruity odor on the breath is a sign of diabetic ketoacidosis (DKA) (hyperglycemia).
C. Vomiting is more common in hyperglycemia/DKA rather than hypoglycemia.
D. Hypoglycemia presents with cool, clammy skin, sweating, confusion, and tremors due to the release of epinephrine.
Correct Answer is B
Explanation
A. Impaired immunity. – Incorrect. While anemia may weaken overall health, hemoglobin levels of 10 g/dL do not significantly affect immune function.
B. Hypoxia. – Correct Answer. Hemoglobin carries oxygen in the blood, and low levels can lead to decreased oxygen delivery to tissues, causing hypoxia.
C. Fluid retention. – Incorrect. Anemia does not directly cause fluid retention.
D. Prolonged bleeding. – Incorrect. While severe anemia can be associated with bleeding disorders, a hemoglobin level of 10 g/dL does not significantly impair clotting.
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