The nurse is caring for a patient with a complete spinal cord injury at the level of C7. Which intervention would the nurse implement in order to prevent complications related to immobility?
Frequent passive range of motion
Coughing and deep breathing exercises once per shift
Turn patient every 4 hours
Ambulate patient twice per shift
The Correct Answer is A
A. Frequent passive range of motion exercises are crucial for preventing complications of immobility, such as contractures and pressure ulcers, and to promote circulation in patients with spinal cord injuries.
B. While coughing and deep breathing exercises are important for respiratory health, they should be performed more frequently than once per shift in patients with reduced mobility to prevent respiratory complications.
C. Turning the patient every 4 hours may not be adequate to prevent pressure ulcers; typically, patients should be turned at least every 2 hours.
D. Patients with a complete spinal cord injury at C7 typically lack the ability to ambulate, making this intervention inappropriate.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Expecting a patient to display preinjury personality traits may not be feasible, as head injuries can lead to permanent personality changes.
B. Actively participating in rehabilitation is a realistic goal that focuses on the patient's engagement in the recovery process, which can improve functional outcomes.
C. Returning to a specific job, such as a corporate attorney, may not be a realistic goal initially and depends on the extent of cognitive recovery.
D. Recalling childhood events is not a priority goal in rehabilitation; functional and recovery-focused goals are more relevant.
Correct Answer is ["A","C","E"]
Explanation
A. Blood pressure monitoring is essential, as spinal cord injuries at high levels can cause disruptions in autonomic regulation, leading to significant blood pressure fluctuations.
B. Bladder function is impacted by spinal cord injuries; however, it is not the initial priority in an emergency setting when life-threatening complications must be managed first.
C. Heart rate is critical as high spinal cord injuries can impact cardiac function by affecting autonomic control, potentially leading to bradycardia.
D. Reflexes are often assessed in cases of spinal injury, but they are not the immediate priority when stabilizing the patient upon arrival.
E. Respirations are a priority, as a C1 spinal cord injury can compromise respiratory function, necessitating immediate assessment to ensure adequate oxygenation and airway management.
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