Nokea
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.
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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.
A nurse assesses a client with multiple sclerosis after administering prescribed fingolimod (Gilenya). For which adverse effect should the nurse monitor?
- A. Peripheral edema
- B. Black and tarry stools
- C. Bradycardia
- D. Nausea and vomiting
Correct Answer: C
Rationale: Fingolimod (Gilenya) can cause bradycardia, especially within the first 6 hours after administration. Peripheral edema, black and tarry stools, and nausea and vomiting are not typical adverse effects of this medication.
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 teaches a client with a lower motor neuron lesion who wants to achieve bladder control. Which statement should the nurse include in this client's teaching?
- A. Stroke the inner aspect of your thigh to initiate voiding.
- B. Implement digital anal stimulation when your bladder is full.
- C. Tighten your abdominal muscles to stimulate urine flow.
- D. Use a catheter to empty your bladder completely.
Correct Answer: C
Rationale: In clients with lower motor neuron injuries, performing a Valsalva maneuver by tightening abdominal muscles can stimulate urine flow. The other options are not effective for achieving bladder control in this context.
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.