A nurse is caring for a client who has a thoracic spine injury. Which of the following actions should the nurse take when turning the client?

Place a pillow under the client's knees when changing positions.

Use a sheet when repositioning the client onto his side.

Apply an immobilizing collar on the client prior to movement.

Instruct the client to keep his arms at his side when altering positions.

Answer and Explanation

The Correct Answer is B

Rationale:

A. Place a pillow under the client's knees when changing positions: Elevating the knees with a pillow may be appropriate for comfort, but in a client with a thoracic spine injury, this can alter spinal alignment and increase the risk of further injury. Maintaining proper spinal alignment during all movements is more important than knee elevation.

B. Use a sheet when repositioning the client onto his side: Using a sheet for logrolling or turning helps maintain spinal alignment and allows multiple caregivers to move the client safely as a unit. This technique minimizes rotation or flexion of the spine, which is critical in preventing further spinal cord injury in clients with thoracic spine trauma.

C. Apply an immobilizing collar on the client prior to movement: Cervical collars are used for cervical spine injuries, not thoracic spine injuries. Applying a collar would not stabilize the thoracic spine and could give a false sense of security while performing repositioning.

D. Instruct the client to keep his arms at his side when altering positions: The client may need to assist in turning if possible, and keeping the arms rigidly at the side is not necessary. Restricting arm movement does not ensure spinal safety and may limit the client’s ability to participate safely in repositioning.

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Free Nursing Study Resources

Correct Answer is C

Explanation

Rationale:

A. Suction the client every 2 hr: Frequent suctioning can increase intracranial pressure due to stimulation of the airway and coughing reflex. Suctioning should be performed only when necessary and with careful monitoring of ICP, rather than routinely every 2 hours.

B. Maintain ICP at 20 mm Hg: Normal ICP ranges from 5 to 15 mm Hg. An ICP of 20 mm Hg or higher indicates increased intracranial pressure and requires intervention. Planning to maintain ICP at this elevated level is unsafe and not appropriate for care planning.

C. Avoid overstimulation of the client: Minimizing noise, unnecessary procedures, and environmental stimuli helps prevent spikes in ICP. Overstimulation can increase cerebral metabolic demand and worsen intracranial hypertension, so this intervention supports ICP management and neurologic stability.

D. Keep the client in a supine position: Supine positioning can impair venous drainage from the brain, potentially increasing ICP. Elevating the head of the bed to 30 degrees while maintaining spinal precautions is preferred to promote venous outflow and reduce intracranial pressure.

A. "Your provider understands your illness and is acting according to your best interests” B. "I know you will be able to recover faster at home." C. "I will tell the provider about your concerns." D. "I will contact your insurance company to see if they will pay for you to be here longer."

Correct Answer is C

Explanation

Rationale:

A. "Your provider understands your illness and is acting according to your best interests.": This statement does not address the client’s concerns and may minimize their feelings. It shifts focus away from the client’s perspective rather than supporting their right to express concerns about discharge timing.

B. "I know you will be able to recover faster at home.": This statement assumes the provider’s decision is correct and discourages the client from expressing concerns. It does not advocate for the client or ensure their voice is heard in care planning.

C. "I will tell the provider about your concerns.": Communicating the client’s concerns to the provider demonstrates client advocacy. The nurse acts on behalf of the client to ensure their preferences, questions, and safety needs are considered in the discharge decision.

D. "I will contact your insurance company to see if they will pay for you to be here longer.": While insurance involvement may be relevant, the primary role of the nurse as an advocate is to convey the client’s concerns to the healthcare team rather than directly managing insurance coverage issues.

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Body system	Findings
Neurologic	Client is awake, alert, oriented x3
Cardiovascular	Client reports no palpitations, heart rhythm regular. Right lower extremity +2 edema from ankle to below the knee joint. Skin warm and inflamed: +2 pedal pulses present in bilateral extremities
Musculoskeletal	Client reports no groin pain, has slight limp with weight bearing on the right extremity

A nurse is caring for a client who has a thoracic spine injury. Which of the following actions should the nurse take when turning the client?

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