On admission to the emergency department, a patient with a C5 compression fracture can move only his head and has flaccid paralysis of all extremities. The distraught family asks if the paralysis is permanent. Which is the best response by the nurse?
"It is too early to tell. When the spinal shock subsides, we will know more."
"You should talk to your physician about things of that nature."
"No. Significant recovery of function should occur in a few days."
"Yes. In all likelihood, the paralysis is probably permanent."
The Correct Answer is A
A. "It is too early to tell. When the spinal shock subsides, we will know more."
This response is appropriate. Spinal shock can initially obscure the extent of neurological injury, and it may take time for the full extent of the injury to become apparent. By acknowledging this and suggesting that more information will be available once spinal shock subsides, the nurse provides a realistic perspective without prematurely predicting the outcome.
B. "You should talk to your physician about things of that nature."
This response may come across as dismissive or evasive. While it is true that the physician ultimately determines the patient's prognosis, the family may be seeking reassurance and guidance from the nurse as well.
C. "No. Significant recovery of function should occur in a few days."
This response is overly optimistic and potentially misleading. While some improvement may occur in the days following a spinal cord injury, significant recovery of function within a few days is unlikely, especially in cases of flaccid paralysis of all extremities.
D. "Yes. In all likelihood, the paralysis is probably permanent."
This response is overly pessimistic and lacks sensitivity. It may unnecessarily distress the family and extinguish hope for the patient's recovery.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Nystagmus:
Nystagmus is an involuntary, rhythmic movement of the eyes, which can be rapid and jerky. It is a common neurological manifestation of phenytoin toxicity. Patients experiencing phenytoin toxicity may exhibit horizontal or vertical nystagmus, which can be detected upon physical examination.
B. Strabismus:
Strabismus, also known as crossed eyes or squint, refers to a misalignment of the eyes. While strabismus can have various causes, it is not typically associated with phenytoin toxicity. Therefore, it is less likely to indicate phenytoin toxicity compared to nystagmus.
C. Blurry vision:
Blurry vision, or visual disturbances, can occur in patients experiencing phenytoin toxicity. However, it is a non-specific symptom and can be observed in various other conditions as well. Patients with phenytoin toxicity may experience blurry vision, double vision (diplopia), or other visual disturbances due to the effects of the medication on the central nervous system.
D. Amblyopia:
Amblyopia, also known as lazy eye, is a condition characterized by reduced vision in one or both eyes. It is typically associated with visual development during childhood and is not directly related to phenytoin toxicity. Therefore, it is less likely to indicate phenytoin toxicity compared to nystagmus or other neurological manifestations.
Correct Answer is B
Explanation
A. Intellectual capacity is not affected:
This statement refers to the fact that ALS primarily affects motor neurons, leading to muscle weakness and paralysis, but it typically does not directly impact cognitive function or intellectual capacity. While cognitive impairment is not a hallmark feature of ALS, some individuals may experience changes in cognitive function or behavior, such as executive dysfunction or frontotemporal dementia, in later stages of the disease. However, depression in ALS is not primarily linked to changes in intellectual capacity but rather to other factors such as altered communication, physical limitations, and loss of autonomy.
B. Communication is altered:
ALS can affect the muscles involved in speech and swallowing, leading to difficulties in communicationAs the disease progresses, patients may experience dysarthria (difficulty speaking clearly) and dysphagia (difficulty swallowing), which can impair their ability to communicate effectively with others. Altered communication can result in frustration, social isolation, and feelings of being misunderstood, all of which are risk factors for depression.
C. Mobility is limited:
ALS causes progressive muscle weakness and paralysis, which can significantly impair mobility over time. As the disease advances, individuals with ALS may become increasingly dependent on mobility aids such as wheelchairs or may require assistance with mobility tasks. Limited mobility can lead to feelings of loss of independence, decreased participation in activities, and increased dependence on caregivers, all of which can contribute to depression.
D. Nutritional intake is poor:
ALS can affect the muscles involved in swallowing and chewing, leading to difficulties with eating and drinking. Dysphagia, or difficulty swallowing, is a common symptom in ALS and can result in poor nutritional intake and weight loss. Malnutrition and weight loss are associated with increased morbidity and mortality in ALS, and they can also contribute to feelings of weakness, fatigue, and overall decline in quality of life, which may exacerbate depression.
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