Question

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

Answer 1

Correct Answers:

spastic, involuntary voiding

Rationale :

🧠 Upper motor neuron (UMN) injuries, such as those occurring above the sacral micturition center (typically above T12), result in a spastic neurogenic bladder.

🧠 In this condition, the detrusor muscle contracts involuntarily, and the patient experiences reflexive, uncontrolled bladder emptying (spastic voiding).

🧠 Although the spinal reflex arc is intact, the brain's voluntary control over voiding is lost, leading to incontinence and urgency.

🧠 This contrasts with lower motor neuron injuries (below T12), where the bladder becomes flaccid and areflexic, resulting in retention or overflow incontinence.

🧠 Nursing care focuses on scheduled voiding or intermittent catheterization and bladder retraining to manage incontinence and prevent complications like UTIs or autonomic dysreflexia.

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Answer 2

Correct Answers:

Identify when the client was immunized

Rationale :

🩺 The priority action for a wound sustained by a nail, especially after a delay of 7 days, is to assess for tetanus immunization status.

🩺 Puncture wounds from objects like nails pose a high risk for Clostridium tetani infection, especially if the wound is deep or contaminated.

🩺 If the client hasn’t had a tetanus booster within the last 5 years, a tetanus toxoid (Td or Tdap) injection should be administered promptly.

🩺 Although wound cleansing and dressing are also essential, infection prevention through immunization is the priority in this time-sensitive scenario.

🩺 This decision follows the nursing priority principle of "prevention over treatment" when managing potential life-threatening conditions.

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Answer 3

Correct Answers:

A Patient who developed a new cough after eating breakfast

Rationale :

🩺 A new cough after eating is a priority assessment concern due to the risk of aspiration in cognitively impaired patients.

🩺 Clients with dementia may have impaired swallowing (dysphagia), which increases the risk of aspiration pneumonia, a potentially fatal complication.

🩺 This client requires immediate evaluation to assess airway patency, oxygenation, and possible need for dietary modification or a swallowing study.

🩺 The other issues (noncompliance with meds, constipation, and pressure ulcer) are important but not immediately life-threatening.

🩺 Respiratory changes always take precedence under the ABC (Airway, Breathing, Circulation) framework.

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Answer 4

Correct Answers:

pain

Rationale :

🩺 Trigeminal neuralgia causes intense, unilateral facial pain, often triggered by minimal stimuli like chewing, brushing teeth, or even wind.

🩺 The paroxysmal nature of pain severely impacts daily functioning, eating, and speaking, making it the most life-altering symptom.

🩺 Although social withdrawal and poor hygiene may result from pain avoidance, they are secondary effects rather than primary manifestations.

🩺 Lethargy is not a hallmark symptom of trigeminal neuralgia.

🩺 Managing pain with anticonvulsants (e.g., carbamazepine) and supportive care is the cornerstone of improving the patient’s quality of life.

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Answer 5

Correct Answers:

bradycardia
hypotension

Rationale :

🔶 C. Bradycardia

🔶 Neurogenic shock results in loss of sympathetic tone, including the cardiac accelerator fibers located between T1–T4.

🔶 This sympathetic disruption leads to dominance of the parasympathetic nervous system, specifically the vagus nerve, which slows the heart rate.

🔶 Unlike other forms of shock where tachycardia compensates for hypotension, neurogenic shock is distinct because it causes bradycardia, making it a key diagnostic feature.

🔶 Clinical observation of heart rates below 60 bpm in the context of a recent spinal injury strongly suggests neurogenic shock.

🔶 E. Hypotension

🔶 Hypotension in neurogenic shock is due to massive vasodilation from the loss of sympathetic vasomotor control, especially below the level of the spinal lesion.

🔶 This vasodilation results in venous pooling in the extremities and a drop in systemic vascular resistance, which lowers blood pressure.

🔶 Despite adequate or even reduced volume, the body cannot constrict blood vessels or raise the heart rate, worsening the hypotension.

🔶 It is one of the earliest and most dangerous signs following high thoracic or cervical spinal cord injury and requires urgent stabilization.

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Answer 6

Correct Answers:

The purpose of this device is to immobilize the cervical spine."

Rationale :

🔷 A halo fixation device is used to immobilize the cervical spine after a spinal cord injury, particularly fractures or dislocations in the cervical region.

🔷 The device consists of a metal halo ring secured to the skull with pins, which is attached to a vest worn around the chest to maintain spinal alignment and prevent movement.

🔷 Immobilization is critical to promote spinal healing and prevent further neurological damage, especially during the acute phase of injury.

🔷 Clients should be taught not to manipulate the screws or pins, and the area under the vest should be kept clean and dry—powders and lotions can lead to skin irritation or infection.

🔷 This is a non-removable, rigid system that ensures stability until bone healing or fusion is sufficient.

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Answer 7

Correct Answers:

Acute delirium

Rationale :

🔸 Acute delirium is a sudden, reversible cognitive disturbance often associated with substance withdrawal, infections, or metabolic imbalances.

🔸 The client's rapid mood fluctuations and hallucinations (e.g., believing the King of England is in the room) are classic signs of delirium, not dementia, which has a gradual onset.

🔸 Alcohol withdrawal delirium (delirium tremens) often emerges 48–72 hours after the last drink and may include confusion, hallucinations, autonomic instability, and agitation.

🔸 Accurate documentation is critical as it ensures timely medical intervention, such as benzodiazepines for alcohol withdrawal.

🔸 Delirium requires immediate attention due to the risk of seizures, injury, or cardiac complications.

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Answer 8

Correct Answers:

Gather supplies and at least 3 other people

Rationale :

🔸 Bathing a client with a spinal cord injury, especially one with cervical tongs or a halo device, requires strict spinal precautions and multiple caregivers to ensure proper alignment and safety.

🔸 Sudden movements or improper turning can worsen the spinal injury, so team assistance is essential during repositioning or hygiene activities.

🔸 The nurse should never manipulate the device or encourage independent movement that risks spinal instability.

🔸 Planning ahead by gathering supplies minimizes the time spent out of safe alignment and avoids unnecessary strain or exposure.

🔸 This approach also helps maintain the client’s dignity and reduces anxiety by performing the task efficiently and safely.

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Answer 9

Correct Answers:

Keep window blinds open during the day

Rationale :

🌞Sundowning refers to increased confusion and agitation during late afternoon/evening in clients with dementia.

🌞 Keeping window blinds open during the day helps reinforce the sleep-wake cycle by supporting circadian rhythms through natural light exposure.

🌞 This environmental cue enhances daytime alertness and nighttime restfulness, reducing the likelihood of sundowning behaviors.

🌞While quiet environments are important, daily light exposure is the most foundational intervention for sundowning.

🌞 Supporting orientation to daylight vs. darkness improves cognitive stability and minimizes restlessness in the evening.

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Answer 10

Correct Answers:

Place a pillow between the knees and ankles

Rationale :

🌼 A side-lying client with partial paralysis is at risk for skin breakdown and joint contractures.

🌼 Placing a pillow between knees and ankles helps align the hips, knees, and ankles, reducing pressure and friction.

🌼 This intervention also supports circulatory flow and prevents skin-to-skin contact, which can cause sores.

🌼 It's a standard practice in pressure injury prevention for immobilized or partially mobile clients.

🌼 Other options are not directly related to preventing complications from repositioning.

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QLexNursing

1 :
Which of the following manifestations can the nurse expect in a client with upper motor neuron deficit related to a spinal cord injury?

2 :
A client arrives reporting redness, warmth, and swelling after stepping on a nail one week ago. What is the nurse's priority action?

3 :
After receiving change-of-shift report for clients on the memory unit, which patient will the nurse see first?

4 :
A client with a diagnosis of trigeminal neuralgia reports which of the following manifestations as significantly affecting her quality of life?

5 :
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

6 :
A nurse is teaching the family of a client who is receivingtreatment for a spinal cord injury with a halo fixation device. Which of the following statements should the nurse make?

7 :
A 45 year old client with a history of drug and alcohol abuse is admitted to the hospital. On day 2 the client has rapidly fluctuating moods and believes the King of England is in his room. How will the nurse document these findings?

8 :
A nurse prepares to bathe a client with a spinal cord injury. Which of the following is the best first action?

9 :
The day shift nurse at the long-term care facility learns that a patient with dementia experienced sundowning late in the afternoon on the previous two days. Which is the best action by the nurse?

10 :
A client who suffered partial paralysis is repositioned by the nurse every 2 hours. After placing the client in a side-lying position, what action will nurse take to prevent complications?

QLexNursing

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

2 : A client arrives reporting redness, warmth, and swelling after stepping on a nail one week ago. What is the nurse's priority action?

3 : After receiving change-of-shift report for clients on the memory unit, which patient will the nurse see first?

4 : A client with a diagnosis of trigeminal neuralgia reports which of the following manifestations as significantly affecting her quality of life?

5 : 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

6 : A nurse is teaching the family of a client who is receivingtreatment for a spinal cord injury with a halo fixation device. Which of the following statements should the nurse make?

7 : A 45 year old client with a history of drug and alcohol abuse is admitted to the hospital. On day 2 the client has rapidly fluctuating moods and believes the King of England is in his room. How will the nurse document these findings?

8 : A nurse prepares to bathe a client with a spinal cord injury. Which of the following is the best first action?

9 : The day shift nurse at the long-term care facility learns that a patient with dementia experienced sundowning late in the afternoon on the previous two days. Which is the best action by the nurse?

10 : A client who suffered partial paralysis is repositioned by the nurse every 2 hours. After placing the client in a side-lying position, what action will nurse take to prevent complications?

1 :
Which of the following manifestations can the nurse expect in a client with upper motor neuron deficit related to a spinal cord injury?

2 :
A client arrives reporting redness, warmth, and swelling after stepping on a nail one week ago. What is the nurse's priority action?

3 :
After receiving change-of-shift report for clients on the memory unit, which patient will the nurse see first?

4 :
A client with a diagnosis of trigeminal neuralgia reports which of the following manifestations as significantly affecting her quality of life?

5 :
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

6 :
A nurse is teaching the family of a client who is receivingtreatment for a spinal cord injury with a halo fixation device. Which of the following statements should the nurse make?

7 :
A 45 year old client with a history of drug and alcohol abuse is admitted to the hospital. On day 2 the client has rapidly fluctuating moods and believes the King of England is in his room. How will the nurse document these findings?

8 :
A nurse prepares to bathe a client with a spinal cord injury. Which of the following is the best first action?

9 :
The day shift nurse at the long-term care facility learns that a patient with dementia experienced sundowning late in the afternoon on the previous two days. Which is the best action by the nurse?

10 :
A client who suffered partial paralysis is repositioned by the nurse every 2 hours. After placing the client in a side-lying position, what action will nurse take to prevent complications?