The client diagnosed with paraplegia is being admitted to a medical unit from home with a stage IV pressure injury over the right ischium. Which assessment tool should be completed on admission to the hospital?

Monitor the Glasgow Coma Scale.

Complete the Braden Scale.

Initiate a Brudzinski flow sheet.

Assess for Babinski's sign.

Answer and Explanation

The Correct Answer is B

Choice A reason:

Monitoring the Glasgow Coma Scale (GCS) is used to assess a client's level of consciousness, typically in cases of head injury or altered mental status. It is not relevant to the assessment of a pressure injury, which requires evaluating the risk factors and extent of skin damage.

Choice B reason:

Completing the Braden Scale is the appropriate action for assessing a client with a pressure injury. The Braden Scale evaluates risk factors for pressure ulcers, including sensory perception, moisture, activity, mobility, nutrition, and friction/shear. This tool helps in creating an effective care plan to prevent further skin breakdown and manage existing ulcers.

Choice C reason:

Initiating a Brudzinski flow sheet pertains to neurological assessment, specifically testing for signs of meningitis. It is not relevant to the assessment or management of pressure injuries in a paraplegic client.

Choice D reason:

Assessing for Babinski's sign is a neurological test to evaluate corticospinal tract function. While important in a complete neurological examination, it does not address the specific needs related to pressure injury assessment and management.

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Correct Answer is C

Explanation

Choice A reason: Clostridium difficile is a bacterium that can cause severe diarrhea, but it is usually associated with recent antibiotic use or hospitalization. The immediate onset of diarrhea after starting enteral feeding points to a more direct cause related to the feeding itself.

Choice B reason: Antibiotic therapy can lead to diarrhea by disrupting the normal gut flora, but the scenario describes an immediate response to enteral feeding, making this option less likely as the primary cause.

Choice C reason: This is the correct answer. Formula intolerance is a common cause of diarrhea soon after starting enteral feeding. The patient's gastrointestinal system may be reacting to the components of the formula, leading to symptoms like diarrhea.

Choice D reason: Bacterial contamination can cause diarrhea, but it generally does not result in immediate symptoms right after starting enteral feeding. Proper handling and preparation of enteral feeds are essential to prevent contamination, but the rapid onset in this scenario suggests formula intolerance.

A. Fat embolism syndrome B. Malignant hyperthermia C. Acute compartment syndrome D. Myocardial embolus

Correct Answer is C

Explanation

Choice A reason:

Fat embolism syndrome is a serious complication of fractures, particularly long bone fractures, and presents with symptoms such as respiratory distress, cerebral dysfunction, and petechial rash. However, it is not characterized by localized increasing edema and pain.

Choice B reason:

Malignant hyperthermia is a severe reaction to certain anesthetic agents and is characterized by hyperthermia, muscle rigidity, and metabolic acidosis. It is not related to increasing edema and pain in the context of a crush injury.

Choice C reason:

Acute compartment syndrome is characterized by increasing pain that is not relieved by analgesics and increasing edema due to increased pressure within the muscle compartments. This condition requires immediate medical intervention to prevent permanent damage.

Choice D reason:

A myocardial embolus would present with symptoms related to cardiac function, such as chest pain and shortness of breath. It is not related to localized increasing edema and pain in the lower extremities following a crush injury.

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The client diagnosed with paraplegia is being admitted to a medical unit from home with a stage IV pressure injury over the right ischium. Which assessment tool should be completed on admission to the hospital?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The patient has just been started on enteral feeding and has developed diarrhea after being on the feeding for 2 hours. What does the nurse suspect is the most likely cause of the diarrhea?

Correct Answer is C

Explanation

Correct Answer is C

Explanation

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