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.

Answer and Explanation

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.

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

Explanation

Choice A reason:

Increased oxygen saturation is not typically associated with neurogenic shock. Neurogenic shock usually involves bradycardia, hypotension, and potential respiratory issues, but not an increase in oxygen saturation.

Choice B reason:

Urine output less than 30 mL/hr is a sign of decreased perfusion to the kidneys, which can occur in neurogenic shock due to hypotension. This reduced urine output is a concerning manifestation that the nurse should monitor closely.

Choice C reason:

A decreased level of consciousness can be related to many factors, including hypoxia, hypotension, or other complications from the spinal cord injury. While it is an important sign to monitor, it is not a definitive marker of neurogenic shock.

Choice D reason:

A heart rate of 34 beats/min (bradycardia) is a common sign of neurogenic shock, which results from the loss of sympathetic tone due to the spinal cord injury. Bradycardia and hypotension are key indicators of neurogenic shock.

A. Suctioning the patient on a regular schedule. B. Adherence to proper hand hygiene. C. Administering antiulcer medication. D. Providing oral care per protocol. E. Elevating the head of the bed.

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

Explanation

Choice A reason:

Suctioning the patient on a regular schedule is not recommended as it can increase the risk of infection and trauma to the airway. Suctioning should be done as needed based on clinical assessment.

Choice B reason:

Adherence to proper hand hygiene is a fundamental practice in preventing infections, including ventilator-associated pneumonia. Hand hygiene helps prevent the transmission of pathogens.

Choice C reason:

Administering antiulcer medication is important for preventing stress ulcers but is not directly related to preventing ventilator-associated pneumonia.

Choice D reason:

Providing oral care per protocol is essential in reducing the risk of ventilator-associated pneumonia. Oral care helps decrease the bacterial load in the oropharynx and prevent aspiration of contaminated secretions.

Choice E reason:

Elevating the head of the bed to 30-45 degrees helps prevent aspiration of gastric contents and is a key practice in preventing ventilator-associated pneumonia.

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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:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse assesses a patient who experienced a spinal cord injury at the T5 level 24 hours ago. Which manifestations would the nurse correlate with neurogenic shock? Select all that apply.

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

Explanation

The nurse caring for patients who are mechanically ventilated uses best practices to prevent ventilator-associated pneumonia. What actions are included in this practice?

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

Explanation

The nurse is caring for a patient who is on mechanical ventilation and the high pressure alarm is sounding. Which of the following is the most likely cause?

Which assessment of a patient in shock would give the nurse the most valuable information to determine there is adequate tissue perfusion?

When planning care for a patient on a mechanical ventilator, the nurse understands that the application of positive end-expiratory pressure (PEEP) to the ventilator settings has which therapeutic effect?

During routine suctioning of a client with an endotracheal tube, the patient becomes diaphoretic and nauseous, and the heart rate decreases to 39 beats/min. What is the nurse's best action at this time?

As a community health nurse, you are planning to conduct an education session on prevention strategies for spinal cord injuries. Which population would benefit most from this education?

You are caring for a patient in the ED who came in after a hard tackle in a football game. The x-rays show that he has a fracture of 2 ribs on the right side. Which intervention will the nurse expect for this patient?

A patient presents to the emergency department with signs of an epidural hematoma. Which manifestation is characteristic of this type of hematoma?

A nurse is caring for a client in acute respiratory failure who is receiving mechanical ventilation. Which of the following assessments is the best method to determine the effectiveness of the current treatments?