A nurse is developing a plan of care for a client who has a spinal fracture and complete spinal cord transection at the level of C5. Which of the following rehabilitation goals should the nurse add to the client's plan of care?

Ability to self-feed with the use of adaptive equipment

Ability to achieve independent transfer from bed to wheelchair

Use of a wheelchair with a chin or mouth stick

Independent control of bowel and bladder function

Answer and Explanation

The Correct Answer is A

A.   This is a realistic goal for a C5 injury. Patients can often develop the strength and coordination in their arms to use adaptive equipment like a mobile arm support or a built-up spoon to feed themselves.
B.   This goal is generally not achievable with a C5 injury. Independent transfers require significant lower body strength and coordination, which are completely absent in this case.
C.   This is a potential option, but it's not a rehabilitation goal. It's more of an adaptive equipment recommendation to assist with mobility and independence in tasks like operating computer or phone.

D.   This is not a realistic goal for a complete spinal cord transection at C5. Bowel and bladder function are typically impaired below the level of injury.

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Correct Answer is D

Explanation

Methylprednisolone is a crucial medication in managing anaphylaxis but it takes longer to act compared to epinephrine and is not the immediate first-line treatment.
B. Dobutamine is a vasopressor used to treat heart failure. However, it's not indicated in the initial management of anaphylaxis.
C. Furosemide is a diuretic used for conditions like heart failure and edema. It has no role in treating anaphylaxis.
D. Epinephrine is the first-line treatment for anaphylactic shock. It rapidly reverses the life-threatening effects of anaphylaxis by constricting blood vessels, relaxing airway muscles, and stimulating the heart.

A. Heart rate 160/min B. Hypokalemia C. Mottled skin D. Blood pressure 115/68 mmHg

Correct Answer is A

Explanation

A. Tachycardia is a classic sign of the compensatory stage of shock. The body attempts to increase cardiac output by increasing heart rate to maintain blood pressure.
B. Hypokalemia is more likely to occur in the later stages of shock, as it's associated with tissue breakdown and renal dysfunction.
C. Mottled skin is a sign of the progressive stage of shock, indicating poor peripheral perfusion.
D. Blood pressure 115/68 mmHg: While this might be considered within normal range, it's important to consider the baseline blood pressure of the patient. In the compensatory stage, blood pressure may be maintained, but there are other compensatory mechanisms in place (like increased heart rate) to do so.

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A nurse is developing a plan of care for a client who has a spinal fracture and complete spinal cord transection at the level of C5. Which of the following rehabilitation goals should the nurse add to the client's plan of care?

Nursing Test Bank

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Correct Answer is D

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Correct Answer is A

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A nurse is developing a plan of care for a client who has a spinal fracture and complete spinal cord transection at the level of C5. Which of the following rehabilitation goals should the nurse add to the client's plan of care?