A nurse is reinforcing teaching to a client who has a spinal cord injury about prevention of atelectasis. Which of the following statements should the nurse include in the teaching?
"Strengthen your chest muscles by performing therapy exercises."
"Do panting breaths several times a day."
"Get plenty of rest throughout the day."
"Perform deep coughing twice a day."
The Correct Answer is D
Atelectasis is alveolar collapse caused by impaired ventilation, retained secretions, decreased lung expansion, and ineffective cough mechanisms. Clients with spinal cord injury commonly develop respiratory compromise due to diaphragmatic weakness, reduced chest expansion, mucus retention, and diminished pulmonary clearance capacity.
Rationale:
A. Chest muscle strengthening may improve long-term respiratory endurance but does not directly prevent alveolar collapse in acute pulmonary care. Atelectasis prevention primarily requires airway clearance and lung expansion techniques. Ineffective secretion removal promotes mucus obstruction and reduced alveolar ventilation in immobilized clients.
B. Panting breaths produce shallow respirations that inadequately expand distal alveoli and do not effectively mobilize pulmonary secretions. Atelectasis prevention requires sustained inspiratory effort and forceful secretion clearance techniques. Shallow breathing worsens alveolar collapse and contributes to impaired gas exchange within dependent lung regions.
C. Excessive rest promotes immobility, shallow respirations, and secretion stasis, increasing pulmonary complication risk after spinal cord injury. Respiratory exercises and mobilization improve ventilation and secretion clearance. Prolonged inactivity contributes to hypoventilation and accumulation of retained bronchial secretions within the lower respiratory tract.
D. Deep coughing promotes maximal lung expansion and mobilizes retained respiratory secretions, making it essential for atelectasis prevention. Forceful coughing increases airway clearance and improves oxygenation in clients with weakened respiratory musculature. Effective pulmonary hygiene reduces secretion retention and prevents progressive alveolar collapse.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A seizure involves abnormal electrical activity in the cerebral cortex, resulting in sudden loss of consciousness, involuntary motor activity, autonomic instability, and impaired protective reflexes. Immediate nursing priorities focus on airway protection, injury prevention, and maintaining physiologic safety during active convulsions.
Rationale:
A. Protecting the client from injury is the first priority during an active seizure. The nurse should ensure safety by lowering the bed, padding side rails, and removing nearby objects to prevent trauma. This minimizes risk of physical injury and protects against secondary complications such as head trauma or aspiration.
B. Restraining the client is contraindicated because it increases risk of musculoskeletal injury, fractures, and worsened agitation. Restraints do not stop seizure activity and may cause harm. They can worsen muscle contractions and increase risk of skeletal injury during uncontrolled movements.
C. Giving food during a seizure is unsafe due to loss of protective airway reflexes and high risk of aspiration. Oral intake is contraindicated until full recovery of consciousness. This increases risk of airway obstruction and aspiration pneumonia during altered neurologic status.
D. Inserting a tongue blade is contraindicated and can cause dental injury, oral trauma, or airway obstruction. It does not prevent tongue swallowing and may worsen injury. This practice increases risk of oral trauma and compromised airway patency during seizure activity.
Correct Answer is A
Explanation
The spinal cord is a central component of the central nervous system responsible for conduction of neural impulses between the brain and peripheral nervous system. It facilitates both ascending sensory transmission and descending motor control, enabling coordination of voluntary movement, reflex activity, and integrated neurological function.
Rationale:
A. The spinal cord functions primarily as a conduit for neural transmission, carrying sensory information to the brain and motor commands from the brain to peripheral tissues. It also mediates reflex arcs that allow rapid, involuntary protective responses without cortical involvement.
B. Digestion is regulated by the autonomic nervous system and gastrointestinal hormones, not the spinal cord. While spinal autonomic pathways contribute indirectly, the primary control centers for digestion are located in the enteric nervous system and brainstem structures.
C. Hormone production is an endocrine function carried out by glands such as the pituitary, thyroid, and adrenal glands. The spinal cord has no endocrine role and does not synthesize or secrete hormones involved in metabolic regulation.
D. Blood filtration is performed by the kidneys within the urinary system. The spinal cord has no role in hematologic filtration or waste excretion, as these processes are governed by renal structures and systemic circulatory mechanisms.
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