Nokea
The nurse is admitting a patient with a spinal cord injury. Which of the following collaborative and nursing actions should the nurse do immediately? (Select all that apply.)
- A. Stabilize spine with sand bags
- B. Nasogastric (NG) tube feeding
- C. Ensure patency of airway
- D. Avoidance of cool room temperature
- E. Insert Foley catheter
Correct Answer: A,C,E
Rationale: Immediate care for a patient with a spinal cord injury is to ensure a patent airway, stabilize the spine with a hard collar or sand bags, and insert a Foley catheter. Avoidance of a cool room temperature is not part of immediate care. A tube feeding would not be initiated in the immediate postinjury care period.
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The nurse is caring for a patient with Bell's palsy who refuses to eat while others are present because of embarrassment about drooling. Which of the following responses is best for the nurse to do?
- A. Respect the patient's desire and arrange for privacy at mealtimes.
- B. Teach the patient to chew food on the unaffected side of the mouth.
- C. Offer the patient liquid nutritional supplements at frequent intervals.
- D. Discuss the patient's concerns with visitors who arrive at mealtimes.
Correct Answer: A
Rationale: The patient's desire for privacy should be respected to encourage adequate nutrition and reduce patient embarrassment. Liquid supplements will reduce the patient's enjoyment of the taste of food. It would be inappropriate for the nurse to discuss the patient's embarrassment with visitors unless the patient wishes to share this information. Chewing on the unaffected side of the mouth will enhance nutrition and enjoyment of food but will not decrease the drooling.
Which of the following nursing actions should the home health nurse include in the plan of care for a patient with paraplegia in order to prevent autonomic dysreflexia?
- A. Assist with selection of a high protein diet.
- B. Use quad coughing to assist cough effort.
- C. Discuss options for sexuality and fertility
- D. Teach the purpose of a prescribed bowel program.
Correct Answer: D
Rationale: Fecal impaction is a common stimulus for autonomic dysreflexia. The other actions may be included in the plan of care but will not reduce the risk for autonomic dysreflexia.
The nurse is caring for a patient with a C3 injury who is demonstrating diaphragmatic respirations. Which of the following findings should the nurse expect to assess?
- A. Tachypnea
- B. Hypertension
- C. Hypovolemia
- D. Hypoventilation
Correct Answer: D
Rationale: Hypoventilation almost always occurs with diaphragmatic respirations because of the decrease in vital capacity and tidal volume, which occurs as a result of impairment of the intercostal muscles.
The nurse is caring for a patient who has Guillain-Barré syndrome. Which of the following assessment data obtained by the nurse will require the most immediate action?
- A. The patient has continuous drooling of saliva.
- B. The patient's blood pressure (BP) is 106/50 mm Hg.
- C. The patient's quadriceps and triceps reflexes are absent.
- D. The patient complains of severe tingling pain in the feet.
Correct Answer: A
Rationale: Drooling indicates decreased ability to swallow, which places the patient at risk for aspiration and requires rapid nursing and collaborative actions such as suctioning and possible endotracheal intubation. The foot pain should be treated with appropriate analgesics, and the BP requires ongoing monitoring, but these actions are not as urgently needed as maintenance of respiratory function. Absence of the reflexes should be documented, but this is a common finding in Guillain-Barré syndrome.
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.