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 A

Explanation

A. Compartment syndrome. The client’s unrelieved pain, despite analgesics, and the presence of swelling distal to the cast are warning signs of compartment syndrome. This is a medical emergency that occurs when increased pressure within a closed muscle compartment reduces blood flow, leading to tissue damage and pain.

B. Muscle wasting. Muscle wasting typically occurs over time due to disuse and is not a sudden, acute complication like compartment syndrome.

C. Skin breakdown. Skin breakdown could occur from improper cast fitting or prolonged pressure, but it would not cause unrelieved pain in the same way as compartment syndrome.

D. Joint stiffness. Joint stiffness can occur in casted limbs after removal, but it is not an acute complication like compartment syndrome.

A. Deficits in the right visual field B. Motor retardation C. Poor impulse control D. Unable to discriminate words and letters

Correct Answer is C

Explanation

A. Deficits in the right visual field: This would be associated with a left-sided stroke, as the right hemisphere controls the left visual field.

B. Motor retardation: This is not a specific sign of right hemisphere stroke. It might be seen with other types of strokes.

C. Poor impulse control: A right hemisphere stroke may cause behavioral changes, including impulsivity, poor judgment, and difficulty in regulating emotions.

D. Unable to discriminate words and letters: This would suggest aphasia, which is typically associated with left hemisphere damage, as the left hemisphere controls language.

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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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Correct Answer is A

Explanation

A nurse is caring for a client who had a stroke involving the right cerebral hemisphere. The nurse should monitor the client for which finding?

Correct Answer is C

Explanation

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