Client with a spinal cord injury
When the nurse is assessing the client With a cord transection above T5 for possible complications, which complication is least likely to occur? A)Diarrhea B) paralytic ileus C) stress ulcers D)intra-abdominal bleeding
A diarrhea
As a first step in teaching a woman with a spinal cord injury and quadriplegia about her sexual health, the nurse assesses her understanding of her current Sexusl functioning. Which statement by the client in case she understands her current ability? A) I won't be able to have sexual intercourse until the urinary catheter is removed. B) I can participate in sexual activity but might not have a orgasm. C) I can't have sexual intercourse because it causes hypertension, but other sexual activity it's OK D) I should be able to participate in sexual activity, but I'll be infertile
B I can participate in sexual activity but might not have an orgasm
When planning to remove a person with a possible spinal cord injury, the nurse should direct the team to move the client using which procedure? A) Limit movement of the arms by wrapping them next to the body. B) Move the person gently to help reduce pain. C) Immobilize the head and neck to prevent further injury. D) Cushion the back with pillows to ensure comfort.
C
A client with a Spinal cord injury who has been active in sports and outdoor activities talks almost obsessively about his past activities. In tears one day he asked the nurse, why can't I stop talking about these things? I know those days are gone forever. Which response by the nurse conveys the best understanding of the clients behavior? A) Be patient it takes time to adjust to such a massive loss. B) Talking about the past is a form of denial we have to help you focus on today. C) Reviewing your loss it is a way to help you work through your grief and loss. D) It's a simple escape mechanism to go back and live in happier times.
C - reviewing your losses is a ways to help work through your grief and loss
A client with a spinal cord injury has spinal shock. What should the nurse expect the clients bladder function to be at this time? A) Spastic B) normal C) atonic D) uncontrolled
C atonic
Caring for a client with a spinal cord injury. The client is experiencing blurred vision and has a blood pressure of 204/102. What should the nurse do first? A) Position the client on the left side. B) Control the environment by turning the lights off and decreasing stimulation for the client. C) Check the clients bladder for distention. D) Administer pain medication.
C check the clients bladder for distention
The client with a spinal cord injury ask the nurse to why the dietitian has recommended to decrease the total daily intake calcium. Which response by the nurse would provide the most accurate information? A) Excessive intake of dairy products makes constipation more common. B) Immobility increases calcium absorption from the intestine. C)Lack of weight bearing causes demineralization of the long bones D) dairy products likely will contribute to gain.
C- Lack of weight bearing causes demineralization of Long bones
After one month of therapy, the client in spinal shock begins to experience muscle spasms in the legs cause the nurse in excitement to report the leg movement. Which response by the nurse would be the most accurate? A) These movements indicate that the damage nerves are healing. B) This is a good sign, keep trying to move all the affected muscles. C) The return of movement means that eventually you should be able to walk again. D) The movements occur from your muscle reflexes cannot be initiated or controlled by the brain.
D
The nurse is assessing a client with a spinal cord injury development of a deep vein thrombosis. Which is the most effective way to determine deep vein thrombosis in this client? A) Detect positive Homans sign B) rate the amount of pain C) assess for tenderness D)measure leg girth
D measure leg girth