Question

A nurse is assessing a client who has a spinal cord injury. Which of the following actions should the nurse take to monitor C4 function?

A. Apply downward pressure while the client shrugs his shoulders upward.
B. Apply resistance while the client lifts his legs from the bed
C. Ask the client to grasp an object and form a fist
D. Apply resistance while the client flexes his arms

Answer 1

To monitor C4 function in a client with a spinal cord injury, the nurse should test the strength of the shoulder muscles by applying downward pressure while the client shrugs their shoulders upward. This method specifically tests the muscles innervated by the C4 nerve and the accessory nerve.

Step-by-step explanation:

The nurse should assess the function of C4 in a client with a spinal cord injury by testing the strength of the muscles that are controlled by the C4 nerve. This can be done by asking the client to shrug their shoulders against resistance, testing the trapezius and other muscles involved in this movement. The action of shrugging shoulders against downward pressure would effectively monitor C4 function and provide insight into the strength and integrity of the accessory nerve, which innervates these muscles.

If muscle tone is present, muscle strength can also be tested by other means, such as having the patient contract muscles against resistance in other parts of the body. However, for C4 assessment, shoulder movement is most relevant. Any lateral differences in strength, or an inability to resist the downward pressure, would suggest a potential impairment of the C4 nerve function or surrounding structures.