A nurse is caring for a client who has a complete spinal cord injury at the level of cervical 7. Which of the following assessment findings should the nurse anticipate?

The client has some sensation but no movement below the level of the injury.

The client has some movement and also some sensation below the level of the injury.

The client has no sensation or movement below the level of the injury.

The client has some movement but no sensation below the level of the injury.

Answer and Explanation

The Correct Answer is C

A. The client has some sensation but no movement below the level of the injury: In a complete spinal cord injury, both motor and sensory function are lost below the level of the lesion. Retaining only sensation without motor function would indicate an incomplete or partial injury rather than a complete transection.

B. The client has some movement and also some sensation below the level of the injury: Presence of both motor and sensory function below the injury would suggest an incomplete spinal cord injury. A complete injury eliminates voluntary movement and sensation below the affected segment.

C. The client has no sensation or movement below the level of the injury: Complete spinal cord injuries at the C7 level result in total loss of motor and sensory function below the lesion. While the client may retain some triceps function (elbow extension) and partial finger extension at the level of the injury, areas below C7 will have absent sensation and movement, consistent with the definition of a complete injury.

D. The client has some movement but no sensation below the level of the injury: Selective loss of sensation while retaining movement is uncommon in complete injuries. This presentation would indicate a rare incomplete injury affecting primarily sensory pathways, not a complete C7 transection.

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Correct Answer is D

Explanation

A. Modest caffeine intake throughout the day: Small amounts of caffeine typically do not provoke seizures in most individuals with epilepsy. While excessive caffeine can increase excitability in some clients, moderate daily intake is generally considered safe and does not serve as a primary seizure trigger.

B. Warm tub baths in the evening: Warm baths promote relaxation and do not usually provoke seizures. In fact, they may help reduce stress, which can indirectly decrease seizure frequency. There is no evidence that routine warm bathing acts as a precipitating factor for epileptic events.

C. Moderate physical exercise: Regular, moderate exercise is encouraged for clients with epilepsy because it promotes cardiovascular health, stress reduction, and overall well-being. Exercise is generally protective and does not increase seizure risk in most individuals when performed safely.

D. Not getting enough sleep at night: Sleep deprivation is a well-established precipitating factor for seizures. Insufficient sleep lowers the seizure threshold by increasing cortical excitability and reducing inhibitory neurotransmission. Clients with epilepsy are advised to maintain consistent sleep schedules and prioritize adequate rest to minimize the risk of seizure occurrence.

A. Administer a nitrate antihypertensive. B. Assess the client for bladder distention. C. Obtain the client's heart rate. D. Place the client in a high-Fowler's position.

Correct Answer is D

Explanation

A. Administer a nitrate antihypertensive: Administering antihypertensives may be necessary if blood pressure remains dangerously high, but pharmacologic intervention is not the first action. Immediate noninvasive measures to reduce the stimulus causing autonomic dysreflexia take priority to prevent further elevation.

B. Assess the client for bladder distention: Bladder distention is a common trigger for autonomic dysreflexia. Identifying and relieving the cause is essential, but assessment requires the client to be safely positioned first to prevent complications from sudden blood pressure elevation.

C. Obtain the client's heart rate: Monitoring heart rate is important for detecting bradycardia associated with autonomic dysreflexia, but it is not the first intervention. Immediate action to lower blood pressure and reduce the risk of stroke or seizure takes precedence.

D. Place the client in a high-Fowler's position: Elevating the head of the bed to a high-Fowler’s position is the first priority because it uses gravity to help lower blood pressure and reduce cerebral perfusion pressure. This immediate action helps prevent life-threatening complications such as stroke, seizure, or myocardial ischemia while the underlying cause is identified and addressed.

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Eye Opening	4 3 2 1	Spontaneous To Verbal Stimuli To Pain No Response
Verbal Response	5 4 3 2 1	Oriented to time, place, person: uses appropriate words and phrases Confused Inappropriate words or verbal response Incomprehensible words No response
Motor Response	6 5 4 3 2 1	Obeys commands Localizes pain Withdraws to pain Flexion to pain (decorticate) Extension to pain (decerebrate) No response

A nurse is caring for a client who has a complete spinal cord injury at the level of cervical 7. Which of the following assessment findings should the nurse anticipate?

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Naxlex Comprehensive Predictor Exams

A nurse is educating a client with epilepsy about strategies to avoid seizure triggers. Which of the following should the nurse discuss as a potential seizure trigger to be avoided?

Correct Answer is D

Explanation

A nurse is caring for a client who has quadriplegia from a spinal cord injury and reports having a severe headache. The nurse obtains a blood pressure reading of 210/108 mm Hg and suspects the client is experiencing autonomic dysreflexia. Which of the following actions should the nurse take first?

Correct Answer is D

Explanation

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