Nokea
Splints have been ordered for a patient who is at risk of developing footdrop following a spinal cord injury. The nurse caring for this patient knows that the splints are removed and reapplied when?
- A. At the patients request
- B. Each morning and evening
- C. Every 2 hours
- D. One hour prior to mobility exercises
Correct Answer: C
Rationale: Splints for footdrop are removed and reapplied every 2 hours to maintain alignment and allow skin inspection. Other schedules are not standard.
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A patient with spinal cord injury has a nursing diagnosis of altered mobility and the nurse recognizes the increased the risk of deep vein thrombosis (DVT). Which of the following would be included as an appropriate nursing intervention to prevent a DVT from occurring?
- A. Placing the patient on a fluid restriction as ordered
- B. Applying thigh-high elastic stockings
- C. Administering an antifibrinolyic agent
- D. Assisting the patient with passive range of motion (PROM) exercises
Correct Answer: B
Rationale: Elastic stockings promote venous return, reducing DVT risk. Fluid restriction increases clotting risk, antifibrinolytics promote clotting, and PROM does not prevent DVT.
A patient who is being treated in the hospital for a spinal cord injury is advocating for the removal of his urinary catheter, stating that he wants to try to resume normal elimination. What principle should guide the care teams decision regarding this intervention?
- A. Urinary retention can have serious consequences in patients with SCIs.
- B. Urinary function is permanently lost following an SCI.
- C. Urinary catheters should not remain in place for more than 7 days.
- D. Overuse of urinary catheters can exacerbate nerve damage.
Correct Answer: A
Rationale: Urinary retention risks autonomic dysreflexia and trauma in SCI patients, guiding cautious catheter removal. Urinary function loss depends on injury level, and catheters do not damage nerves.
The nurse is planning the care of a patient with a T1 spinal cord injury. The nurse has identified the diagnosis of risk for impaired skin integrity. How can the nurse best address this risk?
- A. Change the patients position frequently.
- B. Provide a high-protein diet.
- C. Provide light massage at least daily.
- D. Teach the patient deep breathing and coughing exercises.
Correct Answer: A
Rationale: Frequent position changes prevent pressure ulcers in SCI patients. Diet, massage, and breathing exercises do not directly address skin integrity.
An ED nurse has just received a call from EMS that they are transporting a 17-year-old man who has just sustained a spinal cord injury (SCI). The nurse recognizes that the most common cause of this type of injury is what?
- A. Sports-related injuries
- B. Acts of violence
- C. Injuries due to a fall
- D. Motor vehicle accidents
Correct Answer: D
Rationale: Motor vehicle accidents account for 46% of SCIs, making them the most common cause, followed by falls, violence, and sports injuries.
A patient with a C5 spinal cord injury is tetraplegic. After being moved out of the ICU, the patient complains of a severe throbbing headache. What should the nurse do first?
- A. Check the patients indwelling urinary catheter for kinks to ensure patency.
- B. Lower the height of the bed to improve perfusion.
- C. Administer analgesia.
- D. Reassure the patient that headaches are expected after spinal cord injuries.
Correct Answer: A
Rationale: A severe headache in a C5 SCI patient suggests autonomic dysreflexia, often caused by bladder distension. Checking catheter patency is the priority action.