A nurse is caring for a client with a C5 spinal cord injury. Which of the following activity limitations should the nurse anticipate for this client?
The client will be able to use their hands without assistance.
The client will have some ability to flex their elbows and may transfer assistance.
The client will have full lower extremity function.
The client will be completely independent in all daily self-care activities.
The Correct Answer is B
A spinal cord injury at the C5 level affects motor and sensory function below the fifth cervical vertebra. This level of injury typically results in tetraplegia with significant impairment of both upper and lower extremities, but some shoulder and elbow function may remain intact depending on the extent of the injury. Clients often retain partial ability to flex the elbows, allowing limited independence in activities such as feeding with adaptive devices or assisted transfers. Functional capacity is largely dependent on residual muscle innervation above the level of injury.
Rationale:
A. The client will be able to use their hands without assistance is incorrect because hand and fine motor function are controlled by lower cervical nerves (C6–T1). In a C5 spinal cord injury, hand grasp and finger dexterity are typically lost, requiring assistance or adaptive devices for most self-care activities involving hand use.
B. The client will have some ability to flex their elbows and may transfer with assistance is correct because C5 innervation allows for shoulder abduction and elbow flexion through the biceps muscle. This residual function enables limited independence, such as bringing food to the mouth with assistive devices or participating in assisted transfers using special equipment or caregiver support.
C. The client will have full lower extremity function is incorrect because a C5 spinal cord injury results in loss of motor and sensory function below the level of injury, including the lower extremities. This leads to paralysis of the legs and loss of voluntary movement due to disrupted descending motor pathways.
D. The client will be completely independent in all daily self-care activities is incorrect because a C5 injury results in significant functional limitations requiring assistance for most activities of daily living. Clients typically need help with dressing, bathing, toileting, and mobility, although they may achieve partial independence with adaptive equipment and caregiver support.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Bone marrow suppression leads to decreased production of blood cells, especially white blood cells, red blood cells, or platelets depending on the cause. This condition increases the risk of infection, anemia, and bleeding. Filgrastim is a hematopoietic growth factor used to stimulate neutrophil production and improve immune function in clients with neutropenia. Monitoring improvement focuses primarily on rising white blood cell (WBC) counts, especially neutrophils.
Rationale:
A. A WBC count of 4,800 mm³ indicates improvement because it falls within the lower end of the normal range (approximately 4,000–11,000 mm³). This reflects effective stimulation of bone marrow production by filgrastim and a reduced risk of infection. It shows recovery from neutropenia and improved immune function.
B. A WBC count of 500 mm³ indicates severe neutropenia and a high risk of life-threatening infections. This level reflects significant bone marrow suppression and lack of response to therapy. It is far below normal and represents worsening or unresolved immunosuppression.
C. A hemoglobin level of 11.5 g/dL indicates mild anemia but does not reflect the therapeutic effect of filgrastim. Filgrastim primarily stimulates white blood cell production rather than red blood cell production. Therefore, hemoglobin is not the best indicator of improvement in this case.
D. A platelet count of 150,000 mm³ is within normal limits but does not directly reflect the action of filgrastim. Platelet production is primarily influenced by different growth factors such as thrombopoietin or drugs like oprelvekin. Thus, this value is not the most specific indicator of response to filgrastim therapy.
Correct Answer is ["B","E","F"]
Explanation
Correct placement of an endotracheal tube after intubation is critical to ensure effective ventilation and prevent complications such as esophageal intubation or right mainstem bronchus placement. Verification requires a combination of clinical assessment and objective confirmation. Relying on a single method is unsafe, so multiple validation techniques are used to ensure accurate airway placement and adequate oxygenation.
Rationale:
A. Verifying the color of the tube is not a reliable method to confirm endotracheal tube placement. Tube color does not change based on anatomical position and provides no information about whether the tube is in the trachea or esophagus. This method is not used in clinical practice for confirmation of airway placement.
B. Observing symmetrical chest expansion helps assess whether both lungs are being ventilated. Unequal or absent chest movement may suggest endobronchial intubation or esophageal placement. While helpful, it must be used alongside other objective confirmation methods for accuracy.
C. Administering a dose of oxygen is not a verification method for tube placement. While oxygen delivery is essential after intubation, it does not confirm whether the tube is correctly positioned in the trachea. Oxygen administration is supportive care, not a diagnostic confirmation technique.
D. Measuring the external length of the tube from the lips is a method used to monitor for dislodgement or movement after the initial position has already been confirmed. While it helps ensure the tube stays in the same place (e.g., "22 cm at the teeth"), it cannot prove that the initial placement was in the trachea rather than the esophagus.
E. Auscultating for breath sounds bilaterally is a key method for verifying correct placement. Equal breath sounds over both lung fields suggest tracheal placement, while absent or unequal sounds may indicate esophageal or bronchial intubation. This method should always be combined with additional confirmation techniques.
F. Checking end-tidal carbon dioxide (EtCO₂) levels is the most reliable method for confirming tracheal placement. Presence of sustained CO₂ indicates that the tube is in the airway and that ventilation is occurring. This capnography confirmation is considered the gold standard for verifying correct endotracheal tube placement.
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