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
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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Related Questions
Correct Answer is ["A","B","C"]
Explanation
A. Impaired taste is a common symptom of Bell's palsy due to the involvement of the facial nerve, which carries taste fibers.
B. Pain behind the ear is described as a sharp or aching pain. It is a precursor to facial weakness in many cases.
C. As the facial muscles become weak or paralyzed, it leads to a distorted appearance, such as drooping of the eyelid or mouth.
D. Facial twitching is not a typical symptom of Bell's palsy; instead, the muscles are weakened.
E. Hearing loss is not a typical symptom of Bell's palsy.
Correct Answer is D
Explanation
The client opens his eyes in response to voice, which scores 3 on the eye-opening part of the GCS.
Since the client does not understand questions, this would likely score 1 for verbal response, indicating incomprehensible sounds.
The motor response of bringing an arm up to a trapezius squeeze is localizing pain, which would score 5.
Therefore, the nurse would document the client's GCS score as E3V1M5, which totals to 9 out of a possible 15 points.
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