I client with a spinal cord injury reports hot, burning, tingling, pain that shoots down his extremities. When the client asks why this occurs, what is the nurse's best response?

We need to reposition you.

This is caused by a continual inflammatory process.

This is related to nerve damage in the spinal cord

This will go away in 2 weeks

Answer and Explanation

The Correct Answer is C

Choice A Rationale: Repositioning may be important for preventing complications, but it does not explain the pain described by the client.

Choice B Rationale: A continual inflammatory process is not typically the cause of the pain described by the client with a spinal cord injury.

Choice C Rationale: Nerve damage in the spinal cord is a common cause of neuropathic pain with these characteristics.

Choice D Rationale: Telling the client that the pain will go away in 2 weeks without further assessment or explanation is not accurate and may raise unrealistic expectations.

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Correct Answer is A

Explanation

Choice A Rationale: The purpose of a halo fixation device is to immobilize the cervical spine and prevent movement, which is crucial for healing and preventing further spinal cord injury.

Choice B Rationale: A halo fixation device does not allow for neck movement during the healing process.

Choice C Rationale: Applying talcum powder under the vest may increase the risk of skin irritation or infection.

Choice D Rationale: Turning the screws on the device should only be done by qualified healthcare professionals, not by the family.

A. A measure the calves for symmetry B. B palpate the bladder C. C Place a pillow between the knees and ankles D. D Check the gag reflex

Correct Answer is C

Explanation

Choice A Rationale: Measuring the calves for symmetry is not directly related to preventing complications after repositioning.

Choice B Rationale: Palpating the bladder is important for assessing urinary retention but is not the immediate action to prevent complications after repositioning.

Choice C Rationale: Placing a pillow between the knees and ankles is the correct action to prevent complications such as pressure ulcers and skin breakdown when a client is in a side-lying position.

Choice D Rationale: Checking the gag reflex is unrelated to repositioning and preventing complications.

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I client with a spinal cord injury reports hot, burning, tingling, pain that shoots down his extremities. When the client asks why this occurs, what is the nurse's best response?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is teaching the family of a client who is receiving treatment for a spinal cord injury with a halo fixation device. Which of the following statements should the nurse make?

Correct Answer is A

Explanation

A client who suffered partial paralysis is repositioned by the nurse every 2 hours. After placing the client in a side-lying position, what action will nurse take to prevent complications?

Correct Answer is C

Explanation

The day shift nurse at the long-term care facility learns that a patient with dementia experienced sundowning late in the afternoon on the previous two days. Which is the best action by the nurse?

A nurse is teaching the family of an older adult client who has a new diagnosis of dementia. Which of the following statements should the nurse include in the teaching?

A nurse prepares to bathe a client with a spinal cord injury. Which of the following is the best first action?

A nurse is caring for a client who has quadriplegia from a spinal cord injury and reports having a severe headache. The nurse obtains a blood pressure reading of 210/108 mm Hg and suspects the client is experiencing autonomic dysreflexia. Which of the following actions should the nurse take first?

After assessing a client with deficits from a spinal cord injury, the nurse identifies the client's 02 saturation is 92%. Which of the following is the best first action by the nurse?

The spouse of a 67-yr-old male patient with early stage Alzheimer's disease (AD) tells the nurse, "I am exhausted from worrying all the time. I don't know what to do." Which actions are best for the nurse to take at this time? Select All that Apply

A client complains of back pain after slipping and falling on a wet floor at the hospital. What is the nurses best first action to take?

A nurse is caring for a client who has had a spinal cord injury at the level of the T2-T3 vertebrae. When planning care, the nurse should anticipate which of the following types of disability?