Immediately following a spinal cord injury, a patient asks about the extent of impairment that will result from the injury. The best response by the nurse is:
The extent of your injury cannot be determined until any secondary injury to the cord has resolved.
An MRI can reveal the extent of cord damage.
You will have normal function when spinal shock resolves and the reflex arc returns.
Because rehabilitation can affect the return of function, it will be years before impairment can be determined.
The Correct Answer is A
Choice A reason:
The extent of impairment following a spinal cord injury cannot be determined until any secondary injury to the cord has resolved. Secondary injury, such as inflammation and swelling, can worsen the initial damage and impact the long-term prognosis.
Choice B reason:
An MRI can reveal the extent of cord damage but does not provide a complete picture of the potential functional outcomes. The full extent of impairment cannot be determined solely by imaging.
Choice C reason:
Stating that the patient will have normal function when spinal shock resolves and the reflex arc returns is misleading and overly optimistic. Not all patients will regain normal function after a spinal cord injury, and outcomes vary.
Choice D reason:
While rehabilitation plays a crucial role in recovery, stating that it will be years before impairment can be determined is not entirely accurate. Functional outcomes can often be assessed sooner as the initial recovery phase progresses.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason:
Monitoring sodium levels is important when administering mannitol, but it is not the primary indicator of the drug's effectiveness. Mannitol is an osmotic diuretic used to reduce intracranial pressure, and its effectiveness is better assessed by other means.
Choice B reason:
Fluid intake is important to monitor to ensure proper hydration status, but it does not directly indicate the effectiveness of mannitol. The primary focus should be on the patient's output to assess the diuretic effect.
Choice C reason:
Heart rate monitoring is essential for overall patient care but does not directly indicate the effectiveness of mannitol. Changes in heart rate can occur due to various factors and are not specific to mannitol's action.
Choice D reason:
Urine output is the most direct measure of mannitol's effectiveness. As an osmotic diuretic, mannitol promotes diuresis, and increased urine output indicates that the drug is effectively reducing intracranial pressure.
Correct Answer is B
Explanation
Choice A reason:
Loss of consciousness greater than 30 minutes following injury can occur in various types of head injuries but is not specific to epidural hematomas.
Choice B reason:
Lucid intervals followed by momentary unconsciousness are characteristic of epidural hematomas. Patients with epidural hematomas often experience a period of lucidity following the initial loss of consciousness, followed by a rapid decline in mental status as the hematoma enlarges and increases intracranial pressure.
Choice C reason:
Memory loss of the prior day's activities can occur with various head injuries but is not specific to epidural hematomas.
Choice D reason:
Amnesia of the injury event is common in head injuries but is not specific to epidural hematomas. The hallmark of epidural hematomas is the pattern of lucid intervals followed by rapid deterioration.
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