The nurse is assessing a 28-year-old client who sustained a spinal injury after diving into a shallow pool. Which finding would indicate that the client has a C-1 to C-2 injury?

The client is able to sit erect without assistance

The client is able to move fingers slightly

The client is displaying shallow respirations

The client is able to speak in full sentences

Answer and Explanation

The Correct Answer is C

A. The client is able to sit erect without assistance: This suggests a lower level injury, likely below C-2, as higher injuries often result in paralysis of respiratory muscles.

B. The client is able to move fingers slightly: This would be indicative of a higher level injury, but C-1 to C-2 injuries typically result in complete paralysis below the neck.

C. The client is displaying shallow respirations: Injuries at the C-1 or C-2 level can affect the diaphragm and the ability to breathe deeply, leading to shallow respirations.

D. The client is able to speak in full sentences: A C-1 to C-2 injury would likely affect the ability to speak, as it could impair the phrenic nerve and respiratory muscles needed for adequate breathing and speech.

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Correct Answer is D

Explanation

A. Occurs during stress: This describes stable angina, which is precipitated by predictable stress or exertion.

B. Occurs without any EKG changes: Unstable angina often presents with reversible ischemic EKG changes, such as ST depression or T wave inversion.

C. Occurs with reversible EKG changes: While this is true for unstable angina, it is not the primary differentiator compared to other types of angina.

D. Occurs at rest: Correct. Unstable angina is characterized by chest pain that occurs at rest or with minimal exertion, differentiating it from stable angina.

A. "It is an amino acid which reflects damage to the endothelial lining of arteries. B. "It is a substance composed of free fatty acids reflective of atherosclerosis C. "It is a reliable indicator of the presence of heart failure." D. “It is a protein produced by the liver in response to systemic inflammation."

Correct Answer is C

Explanation

A. "It is an amino acid which reflects damage to the endothelial lining of arteries." BNP is not related to endothelial damage.

B. "It is a substance composed of free fatty acids reflective of atherosclerosis." BNP is not composed of free fatty acids, and it does not reflect atherosclerosis.

C. "It is a reliable indicator of the presence of heart failure." BNP is a hormone released by the heart in response to increased pressure and volume. Elevated levels of BNP are commonly used as a diagnostic marker for heart failure, especially during exacerbations or decompensation.

D. "It is a protein produced by the liver in response to systemic inflammation." BNP is produced by the heart, not the liver.

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The nurse is assessing a 28-year-old client who sustained a spinal injury after diving into a shallow pool. Which finding would indicate that the client has a C-1 to C-2 injury?

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Naxlex Comprehensive Predictor Exams

The nurse is assessing a client with unstable angina. Which finding would the nurse expect the client to report that differentiates this from other types of anginas?

Correct Answer is D

Explanation

The nurse is teaching a group of staff nurses about brain (B-type) natriuretic peptide (BNP). Which statement by the group would indicate that they understand the instruction?

Correct Answer is C

Explanation

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The nurse is assessing a 28-year-old client who sustained a spinal injury after diving into a shallow pool. Which finding would indicate that the client has a C-1 to C-2 injury?

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