A client arrives to the emergency department after falling from a ladder. The client has a loss of sensation and flaccid paralysis. Which of the following complications of an acute spinal cord injury does the nurse suspect?
Hemorrhage
Spinal shock
Apoptosis
Neurogenic shock
The Correct Answer is B
Choice A Reason: Hemorrhage is not a complication of an acute spinal cord injury, but rather a possible cause of it. Hemorrhage can occur due to trauma or rupture of blood vessels in or around the spinal cord, leading to compression and damage of the nerve tissue.
Choice B Reason: This is the correct choice. Spinal shock is a complication of an acute spinal cord injury that occurs within minutes to hours after the injury. It is characterized by loss of sensation, motor function, reflexes, and autonomic function below the level of injury. It is caused by transient disruption of nerve conduction and synaptic transmission in the spinal cord.
Choice C Reason: Apoptosis is not a complication of an acute spinal cord injury, but rather a cellular process that occurs after it. Apoptosis is programmed cell death that occurs in response to injury or stress. It can lead to further loss of neurons and glial cells in the spinal cord over time.
Choice D Reason: Neurogenic shock is a complication of an acute spinal cord injury that occurs within hours to days after the injury. It is characterized by hypotension, bradycardia, and peripheral vasodilation due to loss of sympathetic tone and unopposed parasympathetic activity. It is caused by disruption of autonomic pathways in the spinal cord.

Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: This is correct because resuming a functional role in society is the ultimate goal for a client in the rehabilitative phase of a burn injury. The rehabilitative phase begins when wound healing is complete and lasts until physical and psychosocial recovery is achieved. The nurse should help the client regain independence, self-esteem, and quality of life by providing education, counseling, referrals, and resources.
Choice B reason: This is incorrect because pain management is not a goal, but an intervention for a client in the rehabilitative phase of a burn injury. Pain management is important throughout all phases of burn care, but especially during wound healing and scar formation, which can cause itching, tightness, or hypersensitivity. The nurse should assess the client's pain level and administer analgesics, antipruritics, or moisturizers as ordered.
Choice C reason: This is incorrect because providing continued full support to the client is not a goal, but an intervention for a client in the rehabilitative phase of a burn injury. Providing continued full support to the client can help them cope with physical and emotional challenges, such as scarring, disfigurement, disability, or depression. The nurse should provide emotional support, active listening, positive feedback, and encouragement to the client.
Choice D reason: This is incorrect because preventing infection is not a goal, but an intervention for a client in the rehabilitative phase of a burn injury. Preventing infection is crucial during wound healing and grafting, which can be compromised by bacterial colonization or contamination. The nurse should monitor the client's vital signs, wound appearance, and laboratory results, and administer antibiotics or antiseptics as ordered.
Correct Answer is D
Explanation
Choice A Reason: This is incorrect because earphones are not used in the Rinne test. The Rinne test compares air conduction and bone conduction of sound using a tuning fork.
Choice B Reason: This is incorrect because electrodes are not used in the Rinne test. Electrodes are used in electroencephalography (EEG), which measures brain activity.
Choice C Reason: This is incorrect because a probe is not used in the Rinne test. A probe is used in tympanometry, which measures the pressure and mobility of the eardrum.
Choice D Reason: This is correct because a tuning fork is used in the Rinne test. The tuning fork is placed on the mastoid process behind the ear and then moved near the ear canal to compare the sound perception.

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