Nokea
After a young adult patient has returned home following rehabilitation for a spinal cord injury, the home care nurse notes that the partner is performing many of the activities that the patient had been managing during rehabilitation. Which of the following actions by the nurse is most appropriate at this time?
- A. Tell the partner that the patient can perform activities independently.
- B. Remind the patient about the importance of independence in daily activities.
- C. Develop a plan to increase the patient's independence in consultation with the patient and the partner.
- D. Recognize that it is important for the partner to be involved in the patient's care and support the partner's participation.
Correct Answer: C
Rationale: The best action by the nurse will be to involve all the parties in developing an optimal plan of care. Because family members who will be assisting with the patient's ongoing care need to feel that their input is important, telling the spouse that the patient can perform activities independently is not the best choice. Reminding the patient about the importance of independence may not change the behaviours of the spouse. Supporting the activities of the spouse will lead to ongoing dependency by the patient.
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The nurse is facilitating a bladder training program for a patient who had a spinal cord injury 2 weeks ago and is stable. Which of the following amounts of daily fluid should the nurse include in the patient plan of care to maintain the patient on fluid restriction?
- A. 600-800 mL
- B. 1000-1200 mL
- C. 1400-1600 mL
- D. 1800-2000 mL
Correct Answer: D
Rationale: Many patients are maintained on fluid restriction of 1800-2000 mL/day to facilitate a bladder training program, and urinary output is monitored closely.
The nurse is caring for a patient with paraplegia resulting from a T10 spinal cord injury who has a neurogenic reflex bladder. Which of the following actions should the nurse include in the plan of care?
- A. Educate on the use of the Credé method.
- B. Teach the patient how to self-catheterize.
- C. Catheterize for residual urine after voiding.
- D. Assist the patient to the toilet every 2 hours.
Correct Answer: B
Rationale: Because the patient's bladder is spastic and will empty in response to overstretching of the bladder wall, the most appropriate method is to avoid incontinence by emptying the bladder at regular intervals through intermittent catheterization. Assisting the patient to the toilet will not be helpful because the bladder will not empty. The Credé method is more appropriate for a bladder that is flaccid, such as occurs with a reflexic neurogenic bladder. Catheterization after voiding will not resolve the patient's incontinence.
The nurse is caring for a patient with trigeminal neuralgia who has had a glycerol rhizotomy. Which of the following interventions should the nurse implement?
- A. Ask whether the patient is using an eye shield at night.
- B. Determine whether the patient is doing daily facial exercises.
- C. Question the patient about social activities with family and friends.
- D. Remind the patient to chew food on the unaffected side of the mouth.
Correct Answer: C
Rationale: Because withdrawal from social activities is a common manifestation of trigeminal neuralgia, asking about social activities will help in evaluating whether the patient's symptoms have improved. Glycerol rhizotomy does not damage the corneal reflex or motor functions of the trigeminal nerve, so there is no need to use an eye shield, do facial exercises, or take precautions with chewing.
The nurse is caring for a patient with a neck fracture at the C5 level in the intensive care unit. During initial assessment of the patient, the nurse recognizes the presence of neurogenic shock upon assessing which of the following findings?
- A. Hypotension, bradycardia, and warm extremities
- B. Involuntary, spastic movements of the arms and legs
- C. Hyperactive reflex activity below the level of the injury
- D. Lack of movement or sensation below the level of the injury
Correct Answer: A
Rationale: Neurogenic shock is characterized by hypotension, bradycardia, and vasodilation leading to warm skin temperature. Spasticity and hyperactive reflexes do not occur at this stage of spinal cord injury. Lack of movement or sensation indicates spinal cord injury, but not neurogenic shock.
The nurse is caring for a patient who has halo traction. Which of the following traction weights should the nurse anticipate being used when the traction is first applied?
- A. 1 kg
- B. 10 kg
- C. 8 kg
- D. 5.5 kg
Correct Answer: D
Rationale: The initial weight is typically 4.5-6.8 kg and thereafter approximately 2.2 kg per level with continual neurological monitoring so the only weight value within this normal range is 5.5 kg.