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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Correct Answer is C

Explanation

A. Only 30% of clients did not attend self-management education sessions: This outcome does not directly indicate the effectiveness of a tertiary prevention program, which focuses on managing disease complications and improving quality of life after diagnosis.

B. Average client scores improved on specific risk factor knowledge tests: Improved knowledge is important, but tertiary prevention aims more at managing and reducing the impact of complications in individuals who already have the disease.

C. Clients who developed disease complications promptly received rehabilitation: Tertiary prevention focuses on minimizing the impact of established disease and preventing further disability. Effective rehabilitation for clients with complications demonstrates successful tertiary prevention.

D. More than 50% of at-risk clients were diagnosed early in their disease process: Early diagnosis falls under secondary prevention, not tertiary. Secondary prevention aims to identify and treat disease early to prevent complications, not managing existing complications.

A. Notify the charge nurse the client will need assignment to the COVID-19 specified area of the facility. B. Isolate the client from other clients, family, and healthcare workers not wearing proper PPE. C. Explain to the client to inform others that they may have been potentially exposed in the last 14 days. D. Update the client and family regarding the COVID-19 vaccines that are available.

Correct Answer is B

Explanation

A. Notify the charge nurse the client will need assignment to the COVID-19 specified area of the facility: This is appropriate, but not the most immediate priority. Isolation must occur first to prevent viral spread before formal reassignment can be made.

B. Isolate the client from other clients, family, and healthcare workers not wearing proper PPE: This is the most urgent infection control measure. Isolation limits transmission risk while awaiting test results and is the first step in managing suspected COVID-19 cases.

C. Explain to the client to inform others that they may have been potentially exposed in the last 14 days: This is part of public health tracing but is not the nurse’s immediate clinical priority when caring for a symptomatic client.

D. Update the client and family regarding the COVID-19 vaccines that are available: Vaccine education is important for prevention but not urgent during symptomatic evaluation and isolation of a potentially infectious individual.

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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

The nurse implements a tertiary prevention program for type 2 diabetes mellitus in a rural health clinic. Which outcome indicates that the program was effective?

Correct Answer is C

Explanation

The nurse is preparing to obtain a rapid coronavirus (COVID-19) test for a client who was exposed to the virus eight days ago. The client is experiencing fever, cough, and shortness of breath. Which action is most important for the nurse to take?

Correct Answer is B

Explanation

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