Which observation indicates to the nurse that a patient with quadriplegia spouse understands performance of assistive coughing (quad cough)?

The spouse assists the client into a wheelchair and coaches deep coughing.

The spouse assists the client into high-Fowler position and encourages taking a number of deep breaths.

The spouse places hands on the client's lateral chest and pushes inward on exhalation.

The spouse places hands below the client's diaphragm and pushes upward with exhalation.

Answer and Explanation

The Correct Answer is D

Choice A reason:

While assisting the client into a wheelchair and coaching deep coughing can be beneficial, it does not specifically describe the technique for performing assistive coughing, which is crucial for a quadriplegic patient who cannot generate effective coughs on their own.

Choice B reason:

Placing the client in a high-Fowler position and encouraging deep breaths can be helpful in enhancing lung expansion and breathing, but it does not address the specific method of assistive coughing, which requires manual assistance to be effective.

Choice C reason:

Placing hands on the lateral chest and pushing inward on exhalation is not the correct technique for assistive coughing. This method may not generate sufficient force to help with airway clearance in a quadriplegic patient.

Choice D reason:

Placing hands below the client's diaphragm and pushing upward with exhalation is the correct technique for assistive coughing, also known as quad coughing. This method helps to increase the force of the cough, allowing for better clearance of secretions from the airway, which is essential for patients with quadriplegia.

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Correct Answer is B

Explanation

Choice A reason:

Loss of consciousness greater than 30 minutes following injury can occur in various types of head injuries but is not specific to epidural hematomas.

Choice B reason:

Lucid intervals followed by momentary unconsciousness are characteristic of epidural hematomas. Patients with epidural hematomas often experience a period of lucidity following the initial loss of consciousness, followed by a rapid decline in mental status as the hematoma enlarges and increases intracranial pressure.

Choice C reason:

Memory loss of the prior day's activities can occur with various head injuries but is not specific to epidural hematomas.

Choice D reason:

Amnesia of the injury event is common in head injuries but is not specific to epidural hematomas. The hallmark of epidural hematomas is the pattern of lucid intervals followed by rapid deterioration.

A. Heart rate of 45 beats/min B. SpO2 of 91% C. Blood pressure of 98/62 mmHg D. Loss of motor and sensory function in extremities

Correct Answer is A

Explanation

Choice A reason:

A heart rate of 45 beats/min (bradycardia) is concerning because it indicates a significant impact on the autonomic nervous system, which can occur with high thoracic spinal cord injuries. Bradycardia can lead to inadequate cardiac output and may require immediate intervention to prevent further cardiovascular compromise.

Choice B reason:

An SpO2 of 91% is slightly below normal but not immediately life-threatening. While monitoring and addressing oxygen saturation is important, it is not as critical as the hemodynamic instability indicated by bradycardia in this context.

Choice C reason:

A blood pressure of 98/62 mmHg is on the lower end of the normal range but not immediately alarming. While hypotension is a concern in spinal cord injury patients, the more pressing issue in this scenario is the bradycardia, which can have more immediate and severe consequences.

Choice D reason:

Loss of motor and sensory function in the extremities is a significant finding in spinal cord injuries and indicates the level and severity of the injury. However, it is not immediately life-threatening and does not require as urgent intervention as bradycardia in this acute setting.

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Which observation indicates to the nurse that a patient with quadriplegia spouse understands performance of assistive coughing (quad cough)?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A patient presents to the emergency department with signs of an epidural hematoma. Which manifestation is characteristic of this type of hematoma?

Correct Answer is B

Explanation

A patient is admitted to the emergency department with a spinal cord injury at the level of T2 following a traumatic fall from a roof. Which finding is of most concern to the nurse?

Correct Answer is A

Explanation

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