A nurse assesses a client with paraplegia from a spinal cord...

A nurse assesses a client with paraplegia from a spinal cord injury and notes reddened areas over the client's hips and sacrum. Which actions should the nurse take? (Select all that apply.)

A. Perform range-of-motion (ROM) exercises for the hip joint.
B. Reposition the client off of the reddened areas.
C. Get the client out of bed and into a chair once a day.
D. Obtain a low-air-loss mattress to minimize pressure.
E. Apply a barrier cream to the reddened areas.

Correct Answer: B,D

Rationale: Repositioning and using a low-air-loss mattress relieve pressure on reddened areas. Rubbing, barrier creams, ROM exercises, and sitting in a chair do not address pressure relief effectively.

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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 assesses a client who is recovering from a lumbar laminectomy. Which complications should alert the nurse to urgently communicate with the health care provider? (Select all that apply.)

A. Surgical discomfort.
B. Redness and itching at the incision site.
C. Incisional bulging.
D. Clear drainage on the dressing.
E. Sudden and severe headache.

Correct Answer: C,D,E

Rationale: Incisional bulging, clear drainage (possible CSF leak), and severe headache are emergencies post-laminectomy. Surgical discomfort and redness/itching are normal and not urgent.

A nurse assesses a client who is recovering from anterior cervical diskectomy and fusion. Which complication should the nurse address first?

A. Associated stridor.
B. Weak pedal pulses.
C. Difficulty breathing.
D. Inability to shrug shoulders.

Correct Answer: C

Rationale: Difficulty breathing indicates a potential airway obstruction, possibly due to postoperative swelling, which is a priority. Stridor and difficulty swallowing are also concerns but maintaining an airway takes precedence. Weak pedal pulses and inability to shrug shoulders are less urgent.

A nurse cares for a client with a lower motor neuron injury who is experiencing a flaccid bowel elimination pattern. Which actions should the nurse take to assist in relieving this client's complication? (Select all that apply.)

A. Pour warm water over the perineum.
B. Provide a diet high in fluids and fiber.
C. Administer daily tap water enemas.
D. Massage the abdomen from left to right.
E. Perform manual disimpaction.

Correct Answer: B,D,F

Rationale: For a flaccid bowel due to a lower motor neuron injury, a bowel program including a high-fluid and high-fiber diet, stool softeners, and manual disimpaction if needed is effective. Pouring warm water, daily enemas, and abdominal massage are not appropriate.

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.