A patient with an acute spinal cord injury cannot feel pinprick below the umbilicus but can move both legs weakly. Which documentation is most useful for monitoring neurological change?
Correct answer: A. Record the exact sensory level and grade movement in each limb
- A. Record the exact sensory level and grade movement in each limb
- B. Document only whether the patient reports back pain
- C. Record the blood pressure once during every shift
- D. Describe the legs as normal because some movement remains
Explanation
The sensory level and muscle strength in each limb provide objective data for detecting extension or improvement of cord dysfunction. Preserved movement does not exclude significant injury, and pain or blood pressure alone cannot describe neurological progression.
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About Neurological Nursing
Covers nursing assessment and management of stroke, epilepsy, meningitis, raised intracranial pressure, head injury, spinal cord disorders, Parkinson disease and multiple sclerosis. Key areas include level of consciousness, pupil responses, motor and sensory findings, seizure precautions and distinguishing upper motor neuron from lower motor neuron signs.
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