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 C

Explanation

A. A slight increase in temperature is common after surgery and might not necessarily indicate shock.
B. A slight decrease in respiratory rate is not indicative of shock. In fact, as shock progresses, respiratory rate often increases.
C. An increased heart rate is a classic compensatory mechanism in response to decreased blood volume, as the body tries to maintain blood pressure.
D. While a decrease in urinary output can be a sign of impending shock, it's often a later sign. In the early stages, the body prioritizes blood flow to vital organs, and urine output may still be within normal limits.

A. Bradycardia B. Fever and chills C. Nuchal rigidity D. Severe headache E. Brudzinski's sign

Correct Answer is ["B","C","D","E"]

Explanation

A. Bradycardia is not a typical symptom of meningitis. Instead, meningitis is more likely to cause tachycardia (increased heart rate) as part of the body's response to fever and infection. Bradycardia would not be an expected sign in this context.

B. Fever and chills are common symptoms of meningitis. The infection and inflammation associated with meningitis can cause an elevated body temperature as the body responds to the infection.
C. Nuchal rigidity is a classic sign of meningitis. The inflammation of the meninges causes muscle stiffness and discomfort when trying to bend the neck forward, which is a common finding in this condition.
D. Severe headache is a common symptom of meningitis. The inflammation and irritation of the meninges often result in intense and persistent headaches, which can be one of the primary complaints of patients with meningitis.
E. Brudzinski's sign is a classic clinical sign of meningitis. It indicates meningeal irritation and is often assessed along with other signs to help diagnose meningitis.

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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?

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who returns to the nursing unit from the recovery room after a sigmoid colon resection for adenocarcinoma. The client had an episode of intraoperative bleeding. Which finding indicates to the nurse that the client may be developing hypovolemic shock?

Correct Answer is C

Explanation

What are the anticipated signs and symptoms for a client who has meningitis? (Select all that apply.)

Correct Answer is ["B","C","D","E"]

Explanation

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A nurse is caring for a client who is experiencing hypovolemic shock. Which of the following blood products should the nurse anticipate administering to this client?

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