The nurse is caring for a client who is admitted with head and neck injury following a motor vehicle accident. The nurse should identify which clinical manifestation(s) are associated with a complete transection of the cervical spinal cord? (Select all that apply.)

Poor cough, diaphragmatic breathing.

Absence of sensory and motor function.

Paraplegia.

Intact sensory but absent motor function.

Tetraplegia (quadriplegia).

Answer and Explanation

Correct Answer : A,B,E

Rationale:
A. Poor cough, diaphragmatic breathing: Cervical spinal cord injuries can impair innervation of the diaphragm and accessory muscles, resulting in weak cough and compromised respiratory effort. This is common with high cervical transections and can lead to respiratory complications.

B. Absence of sensory and motor function: A complete transection at the cervical level causes total loss of voluntary motor function and sensation below the level of injury. Both sensory and motor deficits are hallmark features of complete spinal cord injury.

C. Paraplegia: Paraplegia involves paralysis of the lower extremities, typically resulting from thoracic, lumbar, or sacral injuries. It is not characteristic of high cervical cord transection.

D. Intact sensory but absent motor function: This describes a condition such as anterior cord syndrome or incomplete spinal cord injury. Complete transection affects both motor and sensory pathways, so this pattern is inconsistent.

E. Tetraplegia (quadriplegia): Injury at the cervical level affects all four extremities, resulting in tetraplegia. This is a primary manifestation of complete cervical cord transection.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is A

Explanation

Rationale:
A. Transcutaneous pacing: The ECG rhythm demonstrates a third-degree (complete) heart block. This results in severe bradycardia and hypotension (80/50 mm Hg), placing the client at risk for syncope and cardiac arrest. Transcutaneous pacing is the immediate intervention to maintain cardiac output until a permanent pacemaker can be placed.

B. Mechanical ventilation: Although hypotension and bradycardia can lead to hypoxia, the client’s issue is primarily electrical conduction failure, not respiratory compromise. Ventilatory support would not correct the underlying cause of hemodynamic instability.

C. Chest tube insertion: Chest tube insertion is indicated for pneumothorax or hemothorax, not cardiac conduction abnormalities. There is no evidence of respiratory distress or pleural injury requiring this intervention.

D. Synchronized cardioversion: Cardioversion is used for tachydysrhythmias such as atrial fibrillation or supraventricular tachycardia. It is contraindicated in complete heart block, where electrical pacing not shock is required to restore effective cardiac rhythm and perfusion

A. Clear fluid leaking from the nose. B. Sluggish pupillary response to light. C. Periorbital ecchymosis of right eye. D. Troubled with a severe headache.

Correct Answer is A

Explanation

Rationale:
A. Clear fluid leaking from the nose: Clear drainage from the nose following head trauma suggests a cerebrospinal fluid (CSF) leak, often from a basilar skull fracture. This finding requires immediate intervention because it increases the risk of meningitis and indicates a potential breach in the meningeal barrier protecting the brain.

B. Sluggish pupillary response to light: A delayed pupillary reaction may signal mild increased intracranial pressure or localized nerve injury. While important to monitor, it does not demand the same urgent response as a suspected CSF leak.

C. Periorbital ecchymosis of right eye: “Raccoon eyes” or bruising around the eyes may indicate a skull base fracture, but alone it is not an emergency unless accompanied by CSF leakage or neurological deterioration. It should be documented and reported for diagnostic evaluation.

D. Troubled with a severe headache: Headache is a common symptom following head trauma due to concussion or contusion. It requires monitoring and pain management but is not as critical as identifying a CSF leak, which signifies a more severe underlying injury.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

The nurse is caring for a client who is admitted with head and neck injury following a motor vehicle accident. The nurse should identify which clinical manifestation(s) are associated with a complete transection of the cervical spinal cord? (Select all that apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client admitted to the telemetry unit with a diagnosis of syncopal episodes has a sitting blood pressure of 80/50 mm Hg, a regular apical pulse, and a cardiac rhythm as shown on the monitor. The nurse should prepare the client for which procedure?

Correct Answer is A

Explanation

The nurse is completing a head to toe assessment for a client admitted for observation after falling out of a tree. Which finding warrants immediate intervention by the nurse?

Correct Answer is A

Explanation

Exhibits

A client who sustained an L-1 spinal cord injury six months ago that resulted in paraplegia is now experiencing spastic muscle movements in the lower extremities. Which intervention should the nurse implement?

The nurse is reviewing the client's heart rhythm strip. Based on this strip, which interpretation should the nurse make?

When caring for a client who is at risk for increased intracranial pressure (ICP), which intervention should the nurse implement to assist in stabilizing ICР?

A client with a spinal cord injury has urinary retention related to sensorimotor deficits. Which action should the nurse include in the client's plan of care (РOС)?

A client returns to the unit following a cerebral angiogram via the femoral artery that was performed two hours ago. In assessing this client, which finding requires immediate intervention by the nurse?

Patient Data Exhibits The healthcare provider (HCP) would like to do a thoracentesis on the client. The client's caregiver asks the nurse if there are any contraindications for the procedure. Performing a thoracentesis is contraindicated in which clinical manifestation (s)? Select all that apply.