A 70-year-old patient is admitted after falling from his roof. He has a spinal cord injury at the C7 level. What findings during the assessment identify the presence of spinal shock?

Correct Answer: A

Rationale: In this scenario, the correct answer is option A: Paraplegia with a flaccid paralysis. The presence of spinal shock after a spinal cord injury at the C7 level is characterized by a temporary loss of reflexes and muscle tone below the level of injury. This results in flaccid paralysis, where the affected limbs are limp and lack muscle tone. Option B, tetraplegia with total sensory loss, is incorrect because spinal shock typically presents with flaccid paralysis rather than spastic paralysis and is more localized to the area of injury rather than affecting all limbs. Option C, total hemiplegia with sensory and motor loss, is incorrect as hemiplegia refers to paralysis affecting one side of the body, not both sides as seen in this case. Option D, spastic tetraplegia with loss of pressure sensation, is incorrect because spinal shock is characterized by flaccid paralysis, not spastic paralysis. Educationally, understanding the manifestations of spinal shock is crucial for healthcare providers caring for patients with spinal cord injuries. Recognizing the signs of spinal shock helps in providing appropriate interventions and predicting potential outcomes for the patient's recovery and rehabilitation process.

Correct Answer: A

Rationale: In a patient with a T2 spinal cord injury developing paralytic ileus, the nurse should anticipate that the patient will need IV fluids. Paralytic ileus is a condition where there is a loss of normal bowel function due to disruption of nerve impulses in the intestines, which can lead to abdominal distention, pain, and nausea. IV fluids are crucial to maintain hydration and electrolyte balance in these patients, as oral intake may not be possible due to the ileus. Option B, tube feedings, is incorrect because feeding the patient orally or through a tube may worsen the condition by adding more content to the already paralyzed bowel. Option C, parenteral nutrition, is not the first-line treatment for paralytic ileus and is typically reserved for patients who cannot tolerate enteral feeding for an extended period. Option D, nasogastric suctioning, may be used to decompress the stomach and relieve distention but does not address the need for hydration and electrolyte balance. Educationally, understanding the pathophysiology of paralytic ileus following a spinal cord injury is crucial for nurses to provide appropriate care. Recognizing the signs and symptoms of ileus and knowing the appropriate interventions, such as IV fluid administration, is essential for optimizing patient outcomes in such cases.

Correct Answer: B

Rationale: The correct response, option B, is the best choice for the nurse to make because it acknowledges the patient's experience positively and seeks further clarification through demonstration. This response validates the patient's perception of regained function and allows for a more accurate assessment of the movement. It maintains open communication and encourages the patient's active participation in their care. Option A is incorrect as it may dismiss the patient's experience and potentially discourage them. Option C is incorrect because increasing exercise without a proper assessment or understanding of the movement could be detrimental. Option D is incorrect as it could be discouraging and may not provide the patient with the necessary support and encouragement during their recovery. In an educational context, it is vital for healthcare providers to communicate effectively with patients, especially in situations where the patient is recovering from a significant injury like a spinal cord injury. Acknowledging and validating the patient's experiences can foster trust and rapport, which are essential for successful patient outcomes and rehabilitation.

Correct Answer: D

Rationale: The correct answer is D) Have the patient exercise to maintain muscle strength and avoid the risk for falls. As individuals age, there are common changes in the musculoskeletal system such as muscle loss, decreased bone density, and joint stiffness. Encouraging exercise helps maintain muscle strength, joint flexibility, and balance, reducing the risk of falls and promoting overall mobility and independence in older adults. Exercise also helps improve circulation, which can aid in wound healing and skin integrity. Option A is incorrect because while rest is important, encouraging too much rest can lead to muscle atrophy and further exacerbate age-related muscle loss. Option B is incorrect as it promotes dependency, which can negatively impact the patient's autonomy and sense of self. Option C is incorrect as calorie intake alone does not directly address musculoskeletal changes associated with aging; it is important but not the most relevant intervention for this scenario. In an educational context, it's crucial for nurses to understand the importance of promoting physical activity and exercise in older adults to maintain their musculoskeletal health. By incorporating appropriate exercise routines tailored to the individual's needs and abilities, nurses can significantly contribute to enhancing the quality of life and functional capacity of older adult patients.

Correct Answer: C

Rationale: In this scenario, the correct score that the nurse should give for a patient who demonstrates active movement against gravity and some resistance to pressure during muscle strength testing is option C) 4. The rationale behind selecting option C is based on the established criteria for muscle strength testing using the Medical Research Council (MRC) scale. A score of 4 on the MRC scale indicates that the patient is able to move the joint against gravity and provide moderate resistance to pressure applied by the examiner. This level of muscle strength signifies good muscle power and function. Option A) 2 would be incorrect as it represents a score where the patient is only able to move the joint with gravity eliminated. Option B) 3 would also be incorrect as it indicates movement against gravity but no added resistance. Option D) 5 would not be applicable in this case as it signifies full strength with maximal resistance. In an educational context, understanding and applying the MRC scale in muscle strength testing is crucial for healthcare professionals, especially nurses, in assessing and documenting patients' neurological and musculoskeletal status accurately. Proper interpretation of muscle strength scores aids in developing appropriate care plans and monitoring patients' progress effectively.