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Chapter 23: Problem 119

The nurse is caring for a client with a spinal cord injury at the C7 level. Which would not be included in the nursing care plan? A. Monitor neurological status every two hours B. Assess for changes in respiratory function C. Telling the client to turn himself every two hours D. Administering ordered dextran IV to increase capillary blood flow

Short Answer

Expert verified
Answer: Telling the client to turn himself every two hours.

Step by step solution

01

Understand the implications of a C7 level spinal cord injury

A spinal cord injury at the C7 level can cause varying degrees of paralysis or weakness in the arms, hands, trunk, and legs. The client may also experience difficulty in breathing, speaking, and controlling bowel and bladder functions. Therefore, the nursing care plan should primarily focus on monitoring and assisting the client's critical functions such as respiratory and neurological status, as well as ensuring proper positioning and treatment to minimize secondary complications or further damage.
02

Evaluate Option A

Option A states, "Monitor neurological status every two hours." This is an appropriate nursing care plan intervention for a client with a C7 level spinal cord injury because regular monitoring of the client's neurological status can help the nurse detect any changes or deterioration in the client's condition, which can potentially be life-threatening. Therefore, option A should be included in the nursing care plan.
03

Evaluate Option B

Option B states, "Assess for changes in respiratory function." As mentioned earlier, clients with a C7 level spinal cord injury can experience difficulty breathing. Assessing respiratory function regularly is an essential component of the nursing care plan because it will allow the nurse to identify any changes in the client's respiratory function, ensuring prompt intervention if required. Therefore, option B should be included in the nursing care plan.
04

Evaluate Option C

Option C states, "Telling the client to turn himself every two hours." Close attention should be paid to the wording of this option. A client with a C7 level spinal cord injury will most likely have difficulty turning themselves due to paralysis or weakness in the trunk and extremities. While regular turning is essential for preventing pressure ulcers, it will be inappropriate to simply tell the client to turn himself every two hours without providing assistance or using adaptive equipment. Therefore, option C would not be included in the nursing care plan.
05

Evaluate Option D

Option D states, "Administering ordered dextran IV to increase capillary blood flow." This intervention can be beneficial for clients with a spinal cord injury as it can help minimize complications like blood clots or impaired circulation. If the healthcare provider has ordered this treatment, as a part of the nursing care plan, the nurse should administer it to the client as prescribed. Therefore, option D should be included in the nursing care plan.
06

Determine the correct answer

Based on the evaluation of each option, the answer to the question "Which would not be included in the nursing care plan?" is option C: "Telling the client to turn himself every two hours."

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