A client who sustained an L-1 spinal cord injury six months ago that resulted in paraplegia is now experiencing spastic muscle movements in the lower extremities. Which intervention should the nurse implement?

Perform active range of motion exercises.

Apply compression stockings.

Give antispasmodic medications.

Massage the extremities twice a week.

Answer and Explanation

The Correct Answer is C

A. Perform active range of motion exercises: Active ROM exercises are beneficial for maintaining joint mobility and circulation, but they may not sufficiently reduce spasticity in clients with upper motor neuron lesions.

B. Apply compression stockings: Compression stockings help prevent venous thromboembolism and manage edema, but they do not treat muscle spasticity. They offer circulatory support, not neuromuscular control, and therefore would not alleviate the client’s current concern.

C. Give antispasmodic medications: Antispasmodics such as baclofen or tizanidine directly target muscle spasticity by acting on the central nervous system. These medications reduce the frequency and intensity of spasms, improving comfort and mobility in clients with spinal cord injuries.

D. Massage the extremities twice a week: Massage may offer relaxation and temporary relief but is not a primary treatment for spasticity. It does not alter the neurophysiological causes of muscle spasms and is unlikely to produce sustained control over involuntary muscle activity.

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Free Nursing Study Resources

Correct Answer is ["A","D","E"]

Explanation

A. Ask the client if she has any alcohol in the room at this time: This is an essential step in assessing for immediate safety and contraband that may impact her treatment plan, especially considering her symptoms and possible withdrawal risk.

B. Administer a PRN prescription for an antianxiety drug: This could mask symptoms of alcohol withdrawal or interact negatively with alcohol. Medication should be given only after thorough assessment and consultation.

C. Inform the family that they are enabling the client: While family education is important, using accusatory language like "enabling" can damage therapeutic relationships. A nonjudgmental, supportive approach is better.

D. Observe for signs to determine if client is inebriated: Monitoring for inebriation supports accurate clinical assessment and decisions about withdrawal protocols, safety, and medication timing.

E. Schedule a conference with the client and family members: A joint meeting allows open discussion, identifies care goals, and promotes understanding and support from all parties involved.

A. Urinate at a specified time, discard this urine, and collect all subsequent urine during the next 24 hours. B. Urinate immediately into a urinal, and the lab will collect the specimen every 6 hours, for the next 24 hours. C. For the next 24 hours, notify nurse when the bladder is full, and the nurse will collect catheterized specimens. D. Cleanse around the meatus, discard first portion of voiding, and collect the rest in a sterile bottle.

Correct Answer is A

Explanation

A. Urinate at a specified time, discard this urine, and collect all subsequent urine during the next 24 hours: Discarding the first void ensures the collection begins with an empty bladder, and all urine afterward is included for accurate measurement.

B. Urinate immediately into a urinal, and the lab will collect the specimen every 6 hours, for the next 24 hours: This describes timed urine sampling, not a continuous 24-hour collection required for creatinine clearance.

C. For the next 24 hours, notify nurse when the bladder is full, and the nurse will collect catheterized specimens: Routine creatinine clearance testing does not require catheterization unless the client is already catheterized.

D. Cleanse around the meatus, discard first portion of voiding, and collect the rest in a sterile bottle: This describes a midstream or clean-catch technique, typically used for urine cultures, not 24-hour collections.

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A client who sustained an L-1 spinal cord injury six months ago that resulted in paraplegia is now experiencing spastic muscle movements in the lower extremities. Which intervention should the nurse implement?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is ["A","D","E"]

Explanation

The nurse plans to collect a 24 hour urine specimen for a creatinine clearance test. Which instruction should the nurse provide to the adult male client?

Correct Answer is A

Explanation

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