The nurse is assessing a pediatric patient with a spinal cord injury. Which cue should the nurse recognize as a potential indication of spinal cord injury in this patient?

Increased muscle tone

Heightened reflex activity

Loss of function and reflexes below the affected area of the spine

Normal bowel function

Answer and Explanation

The Correct Answer is C

A. Increased muscle tone: Hypertonia may occur later in recovery, but acute spinal cord injury often initially presents with flaccid paralysis rather than increased muscle tone.

B. Heightened reflex activity: Reflexes are typically diminished or absent below the level of injury in the acute phase, so heightened reflexes are not an early indicator of spinal cord injury.

C. Loss of function and reflexes below the affected area of the spine: Acute spinal cord injury commonly results in loss of motor and sensory function as well as absent reflexes below the level of injury, making this a primary clinical cue for assessment.

D. Normal bowel function: Bowel function is often impaired in spinal cord injury due to disruption of autonomic control. Normal function would not indicate the presence of spinal cord injury.

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Correct Answer is D

Explanation

A. Accept, introduce, demonstration, explanation, and teach back: While some words are related to communication, this does not accurately represent the standard AIDET framework used in healthcare.

B. Assessment, implementation, data collection, evaluation, and treatment: This sequence describes aspects of the nursing process, not the AIDET communication tool.

C. Anticipate, identify, develop, encourage, and talk: These terms are not part of the AIDET framework and do not align with the intended client-centered communication steps.

D. Acknowledge, introduce, duration, explanation, and thank you: This correctly represents AIDET. It guides nurses to acknowledge the client, introduce themselves, explain the expected duration of care, provide clear explanations, and thank the client, enhancing communication and the overall healthcare experience.

A. "Establish a consistent bedtime routine and ensure the infant sleeps on their back in a safe sleep environment." B. "Encourage the infant to sleep in the caregivers' bed to reduce anxiety and improve sleep duration." C. "Avoid daytime naps to increase sleep pressure and ensure the infant sleeps longer at night." D. "When the baby is crying, you should rush in to help comfort them and then put them back to bed."

Correct Answer is A

Explanation

A. "Establish a consistent bedtime routine and ensure the infant sleeps on their back in a safe sleep environment.": Consistency in bedtime routines helps infants anticipate sleep, promoting longer and more restorative sleep. Placing the infant on their back in a safe sleep environment reduces the risk of sudden infant death syndrome (SIDS) while supporting healthy sleep patterns.

B. "Encourage the infant to sleep in the caregivers' bed to reduce anxiety and improve sleep duration.": Bedsharing increases the risk of SIDS and is not recommended for infants under 1 year old. Independent sleep in a safe sleep environment is preferred to promote safety and self-soothing skills.

C. "Avoid daytime naps to increase sleep pressure and ensure the infant sleeps longer at night.": Restricting naps can lead to overtiredness, making it harder for the infant to fall asleep and stay asleep. Age-appropriate naps support healthy development and nighttime sleep regulation.

D. "When the baby is crying, you should rush in to help comfort them and then put them back to bed.": While responding to distress is important, immediately rushing in every time may prevent the infant from developing self-soothing abilities. Gradual, consistent approaches are recommended to improve independent sleep.

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The nurse is assessing a pediatric patient with a spinal cord injury. Which cue should the nurse recognize as a potential indication of spinal cord injury in this patient?

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Naxlex Comprehensive Predictor Exams

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