Neurological Disorders Q 26 - Gyan Darpan : Learning Portal
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Tuesday, 19 April 2022

Neurological Disorders Q 26

A male client is admitted with a cervical spine injury sustained during a diving accident. When planning this client’s care, the nurse should assign the highest priority to which nursing diagnosis?
     A. Impaired physical mobility
     B. Ineffective breathing pattern
     C. Disturbed sensory perception (tactile)
     D. Self-care deficit: Dressing/grooming

Correct Answer: B. Ineffective breathing pattern

Because a cervical spine injury can cause respiratory distress, the nurse should take immediate action to maintain a patent airway and provide adequate oxygenation. Maintain patent airway: keep head in neutral position, elevate head of bed slightly if tolerated, use airway adjuncts as indicated. Patients with high cervical injury and impaired gag and cough reflexes require assistance in preventing aspiration and maintaining patient airway.

Option A: Continually assess motor function (as spinal shock or edema resolves) by requesting the patient to perform certain actions such as shrug shoulders, spread fingers, squeeze, release examiner’s hands. Evaluates status of individual situation (motor-sensory impairment may be mixed or not clear) for a specific level of injury, affecting type and choice of interventions.
Option C: Assess and document sensory function or deficit (by means of touch, pinprick, hot or cold, etc.), progressing from an area of deficit to a neurologically intact area. Changes may not occur during acute phase, but as spinal shock resolves, changes should be documented by dermatome charts or anatomical landmarks (“2 in above nipple line”). Provide tactile stimulation, touching the patient in intact sensory areas (shoulders, face, head).
Option D: The other options may be appropriate for a client with a spinal cord injury — particularly during the course of recovery — but don’t take precedence over a diagnosis of ineffective breathing pattern. Plan activities to provide uninterrupted rest periods. Encourage involvement within individual tolerance and ability. Prevents fatigue, allowing opportunity for maximal efforts and participation by patient.

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