Nokea
The health care provider prescribes these interventions for a patient with possible botulism poisoning. Which of the following prescriptions should the nurse question?
- A. Maintain NPO status.
- B. Obtain lumbar puncture tray.
- C. Give magnesium citrate 240 mL stat.
- D. Administer 1500 mL tap water enema.
Correct Answer: C
Rationale: Magnesium is contraindicated because it may worsen the neuromuscular blockade. The other orders are appropriate for the patient.
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In which order will the nurse perform the following actions when caring for a patient with possible C6 spinal cord trauma who is admitted to the emergency department?
- A. Infuse normal saline at 150 mL/hour.
- B. Monitor cardiac rhythm and blood pressure.
- C. Administer O2 using a non-rebreather mask.
- D. Transfer the patient to radiology for spinal computed tomography (CT).
- E. Immobilize the patient's head, neck, and spine.
Correct Answer: E,C,B,A,D
Rationale: The first action should be to prevent further injury by stabilizing the patient's spinal cord. Maintenance of oxygenation by administration of 100% O2 is the second priority. Because neurogenic shock is a possible complication, monitoring of heart rhythm and BP are indicated, followed by infusing normal saline for volume replacement. A CT scan to determine the extent and level of injury is needed once initial assessment and stabilization are accomplished.
The nurse is teaching a patient who is at risk for Bell's palsy because of previous herpes simplex infection. Which of the following information should the nurse include?
- A. Call the doctor if pain or herpes lesions occur near the ear.
- B. Treatment of herpes with antiviral agents prevents Bell's palsy.
- C. You may be able to prevent Bell's palsy by doing facial exercises regularly.
- D. Medications to treat Bell's palsy work only if started before paralysis onset.
Correct Answer: A
Rationale: Pain or herpes lesions near the ear may indicate the onset of Bell's palsy and rapid corticosteroid treatment may reduce the duration of Bell's palsy symptoms. Antiviral therapy for herpes simplex does not reduce the risk for Bell's palsy. Corticosteroid therapy will be most effective in reducing symptoms if started before paralysis is complete but will still be somewhat effective when started later. Facial exercises do not prevent Bell's palsy.
The nurse is caring for a young adult patient with a T3 spinal cord injury who asks the nurse about whether he will be able to be sexually active. Which of the following initial responses by the nurse is best?
- A. Reflex erections frequently occur, but orgasm may not be possible.
- B. Sildenafil is used by many patients with spinal cord injury.
- C. Multiple options are available to maintain sexuality after spinal cord injury.
- D. Penile injection, prostheses, or vacuum suction devices are possible options.
Correct Answer: C
Rationale: Although sexuality will be changed by the patient's spinal cord injury, there are options for expression of sexuality and for fertility. The other information also is correct, but the choices will depend on the degrees of injury and the patient's individual feelings about sexuality.
The nurse is caring for a patient with a T2 spinal cord injury who tells the nurse, 'I feel awful today. My head is throbbing, and I feel sick to my stomach.' Which of the following actions should the nurse take first?
- A. Assess for a fecal impaction.
- B. Give the prescribed antiemetic.
- C. Check the blood pressure (BP).
- D. Notify the health care provider.
Correct Answer: C
Rationale: The BP should be assessed immediately in a patient with an injury at the T6 level or higher who complains of a headache to determine whether autonomic dysreflexia is occurring. Notification of the patient's health care provider is appropriate after the BP is obtained. Administration of an antiemetic is indicated after autonomic dysreflexia is ruled out as the cause of the nausea. The nurse may assess for a fecal impaction, but this should be done after checking the BP and lidocaine jelly should be used when performing a digital rectal exam to prevent further symptoms such as increases in the BP.
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.