Nokea
A nurse assesses a client who is recovering from a diskectomy 6 hours ago. Which assessment finding should the nurse address first?
- A. Pain at the surgical site.
- B. Numbness in the lower extremities.
- C. Difficulty breathing.
- D. Weak pedal pulses.
Correct Answer: C
Rationale: Difficulty breathing could indicate a compromised airway, possibly due to swelling, which is a critical postoperative complication requiring immediate attention. Pain, numbness, and weak pulses are important but not as urgent as airway issues.
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A nurse teaches a client who is recovering from a spinal fusion. Which statement should the nurse include in this client's postoperative instructions?
- A. Only lift items that are 10 pounds or less.
- B. You must wear a brace throughout the healing process.
- C. You must remain in bed for 3 weeks after surgery.
- D. You are prescribed medications to prevent rejection.
Correct Answer: B
Rationale: Clients who undergo spinal fusion are fitted with a brace that they must wear throughout the healing process to stabilize the spine. The other options are incorrect: lifting restrictions may vary, bed rest for 3 weeks is not typically required, and rejection medications are not needed for spinal fusion.
An emergency department nurse cares for a client who experienced a spinal cord injury 1 hour ago. Which prescribed medication should the nurse prepare to administer?
- A. Ibuprofen (Advil)
- B. Methylprednisolone (Medrol)
- C. Atropine sulfate
- D. Etanercept (Enbrel)
Correct Answer: B
Rationale: Methylprednisolone is administered within the first 8 hours of a spinal cord injury to reduce inflammation and improve motor and sensory function. The other medications are not indicated for acute spinal cord injury.
After teaching a male client with a spinal cord injury at the T4 level, the nurse assesses the client's understanding. Which statements indicate a correct understanding of the teaching related to sexual effects of this injury? (Select all that apply.)
- A. I will explore other ways besides intercourse to please my partner.
- B. I will not be able to have an erection because of my injury.
- C. Ejaculation may not be as predictable as before.
- D. I may urinate with ejaculation but this will not cause infection.
- E. I should be able to have an erection with stimulation.
Correct Answer: C,D,E
Rationale: Men with injuries above T6 can often have reflex erections with stimulation. Ejaculation may be less predictable and mixed with urine, which is sterile and does not cause infection. Exploring alternative intimacy methods is also appropriate.
A nurse assesses a client who experienced a spinal cord injury at the T5 level 12 hours ago. Which manifestations should the nurse correlate with neurogenic shock? (Select all that apply.)
- A. Heart rate of 34 beats/min
- B. Blood pressure of 90/60 mm Hg
- C. Cool and clammy skin
- D. Decreased urinary output
- E. Flaccid paralysis below the injury
Correct Answer: A,B,C,D,E
Rationale: Neurogenic shock from a T5 spinal cord injury can cause bradycardia (low heart rate), hypotension (low blood pressure), cool and clammy skin, decreased urinary output due to reduced perfusion, and flaccid paralysis below the injury level.
A nurse cares for several clients on a neurologic unit. Which prescription for a client should direct the nurse to ensure that a medical consent cannot be substituted before the test or procedure?
- A. Sensation measurement via the pinprick method
- B. Computed tomography of the cranial vault
- C. Lumbar puncture for cerebrospinal fluid sampling
- D. Venipuncture for autoantibody analysis
Correct Answer: C
Rationale: A lumbar puncture is an invasive procedure with potential complications, requiring informed consent. The other procedures are noninvasive and do not require consent.