The nurse is providing care for a client who was placed in a halo brace 2 days ago because of a spinal cord injury. Which assessment is the first priority of the nurse?

Loosen all of the connections on the vest to assess the skin

Ask about the client's ability to perform range of motion to legs

Ask how the client is able to reposition self in bed

Assess the pin sites

Answer and Explanation

The Correct Answer is D

Choice A Rationale: Loosening all of the connections on the vest to assess the skin is not the first priority and may compromise the stability of the halo brace.

Choice B Rationale: Asking about the client's ability to perform range of motion to legs is important but may not be the first priority.

Choice C Rationale: Asking how the client is able to reposition self in bed is important but may not be the first priority.

Choice D Rationale: Assessing the pin sites is the first priority in caring for a client with a halo brace, as complications related to pin site infections or issues can have significant consequences. Pin site care and assessment are crucial to prevent infections and complications.

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Correct Answer is ["A","B","D"]

Explanation

Choice A Rationale: A weakened gag reflex is a potential complication of a cervical spinal cord injury and can lead to difficulties in swallowing and increased risk of aspiration.

Choice B Rationale: Hyperthermia can occur as a result of autonomic dysfunction associated with spinal cord injuries, especially when the injury is at a high cervical level.

Choice C Rationale: Absence of bowel sounds is not typically associated with cervical spinal cord injuries but may be seen in lower spinal cord injuries.

Choice D Rationale: Hypotension is a potential complication due to impaired autonomic regulation in cervical spinal cord injuries.

Choice E Rationale: Polyuria is not typically associated with cervical spinal cord injuries but may occur in cases of lower spinal cord injuries affecting bladder function.

A. A Currently pregnant B. B Thyroid disease C. C Seizure disorder D. D Current smoker

Correct Answer is A

Explanation

Choice A Rationale: Being currently pregnant is a risk factor for developing Bell's Palsy.

Choice B Rationale: Thyroid disease is not a direct risk factor or consistent finding in Bell's Palsy.

Choice C Rationale: Having a seizure disorder is not directly related to Bell's Palsy.

Choice D Rationale: Current smoking is not a risk factor associated with Bell's Palsy

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The nurse is providing care for a client who was placed in a halo brace 2 days ago because of a spinal cord injury. Which assessment is the first priority of the nurse?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in the emergency department is monitoring a client who has a cervical spinal cord injury from a fall. The nurse should monitor the client for which of the following complications? (Select all that apply.)

Correct Answer is ["A","B","D"]

Explanation

When reviewing the health history of a client, which of the following finding is consistent with a diagnosis of Bell's Palsy?

Correct Answer is A

Explanation

A client arrives with respiratory muscle weakness, difficulty swallowing and abdominal pain. Which of the following reported by the client's husband is relevant to the client's manifestations?

Which of the following manifestations can the nurse expect in a client with upper motor neuron deficit related to a spinal cord injury?

When addressing the needs of a client with a newly diagnosed spinal cord injury, the nurse understands that which of the following are true about nutritional needs?

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A client has sustained a T4-T5 injury and the nurse suspects he is in neurogenic shock. Which of the following manifestations are consistent with neurogenic shock? Select All that Apply

A nurse is preparing a care plan for a client with a spinal cord injury. Which of the following is the highest priority for the nurse to implement?

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