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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["83"]
Explanation
Rationale:
Total volume to be infused = 500 mL.
Infusion time in minutes = 2 hours × 60 minutes/hour
= 120 minutes.
Drop factor of the IV administration set = 20 gtt/mL.
- Calculate the flow rate in drops per minute (gtt/min).
Flow rate (gtt/min) = (Total volume (mL) × Drop factor (gtt/mL)) / Infusion time (min)
= (500 mL × 20 gtt/mL) / 120 min
= 10000 / 120 gtt/min
= 83.333... gtt/min.
- Round the answer to the nearest whole number.
= 83 gtt/min
Correct Answer is A
Explanation
A. A child with asthma, who takes prednisone and has a fasting serum glucose of 180 mg/dL (10 mmol/L): This client’s fasting glucose is well above the normal range. Prednisone can increase blood glucose levels, placing the child at risk for hyperglycemia. This indicates a need for urgent education on blood glucose management while on steroids.
B. An adolescent male who has type 1 diabetes and a random glucose at 120 mg/dL (6.7 mmol/L): This blood glucose level is within normal limits for random testing. No immediate need for change in diabetic teaching is evident based on this value.
C. A female who has gestational diabetes and has a 1-hour postprandial glucose at 140 mg/dL (7.8 mmol/L): Her result meets the upper limit range for gestational diabetes. While she requires ongoing monitoring, her values do not indicate a need for urgent intervention.
D. An adult who has type 2 diabetes and has a glycosylated hemoglobin (Hb A1C) at 10%: Although this indicates poor long-term control, it reflects a chronic issue. The child with an acutely elevated fasting glucose and corticosteroid use is at greater immediate risk and thus has higher priority for education.
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