Nokea
An emergency room nurse initiates care for a client with a cervical spinal cord injury who arrives via emergency medical services. Which action should the nurse take first?
- A. Assess level of consciousness.
- B. Obtain vital signs.
- C. Administer oxygen therapy.
- D. Evaluate respiratory status.
Correct Answer: D
Rationale: The first priority for a client with a cervical spinal cord injury is to assess respiratory status and airway patency, as these injuries can compromise breathing. Other assessments follow after ensuring airway and breathing are stable.
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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.
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 is teaching a client with multiple sclerosis who is prescribed cyclophosphamide (Cytoxan) and methylprednisolone (Medrol). Which statement should the nurse include in this client's discharge teaching?
- A. Take warm baths to promote muscle relaxation.
- B. Avoid people with upper respiratory illnesses.
- C. Relying on a walker will weaken your gait.
- D. Take prescribed medication only when symptoms occur.
Correct Answer: B
Rationale: Clients taking cyclophosphamide and methylprednisolone are immunocompromised and should avoid people with upper respiratory illnesses to prevent infections. Warm baths may help but are not the priority, relying on a walker does not necessarily weaken gait, and medications should be taken as prescribed, not only when symptoms occur.
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 promotes the prevention of lower back pain by teaching clients at a community center. Which instruction should the nurse include in this education?
- A. Participate in an exercise program to strengthen muscles.
- B. Purchase a mattress that allows you to adjust the firmness.
- C. Wear flat instead of high-heeled shoes to work each day.
- D. Keep your weight within 20% of your ideal body weight.
Correct Answer: A
Rationale: Exercise can strengthen back muscles, reducing the incidence of low back pain. The other options will not prevent low back pain.