Nokea
The nurse is assisting the client who sustained a C5 SCI to cough using the quad coughing technique. The nurse correctly demonstrates quad coughing with which actions? Select all that apply.
- A. Places a suction catheter in the client’s oral cavity to stimulate the cough reflex
- B. Puts hands on the upper abdomen, has client inhale, pushes upward during a cough
- C. Cups the hands and percusses the client’s anterior, lateral, and posterior lung fields
- D. Hyperoxygenates the client by using a resuscitation bag to deliver 100% oxygen
- E. Elevates the head of the bed to a high Fowler’s position if the client is sitting in bed
Correct Answer: B,E
Rationale: Stimulating a cough with a suction catheter is not associated with the quad cough technique, and it may cause regurgitation. The nurse’s hand placement and pushing upward during a cough help to overcome the impaired diaphragmatic function that occurs with a C5 SCI. Cupping the hands and percussing the lung fields is a technique to loosen secretions but is not the quad coughing technique. Hyperoxygenating the client is a measure to prevent hypoxia associated with suctioning but is not included in the quad coughing technique. Elevating the head of the bed will promote lung expansion, thus enabling a stronger cough.
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When implementing seizure precautions, which nursing action is most appropriate?
- A. Move the client to a room closer to the nurses' station.
- B. Serve the client's food in paper and plastic containers.
- C. Maintain the client's bed in the lowest position.
- D. Ensure that soft limb restraints are applied to upper extremities.
Correct Answer: C
Rationale: Maintaining the bed in the lowest position minimizes the risk of injury from falls during a seizure.
Which nursing actions are essential when finding a client experiencing a tonic-clonic seizure? Select all that apply.
- A. Calling out the client's name
- B. Padding the client's body during the seizure activity
- C. Placing an emesis basin close to the client's mouth
- D. Rolling the client's body to the side
- E. Removing environmental hazards to protect the client
- F. Calling the respiratory therapy department
Correct Answer: D,E
Rationale: Rolling the client to the side prevents aspiration, and removing environmental hazards minimizes injury risk during a tonic-clonic seizure.
The home health nurse is caring for a 28-year-old client with a T10 SCI who says, 'I can’t do anything. Why am I so worthless?' Which statement by the nurse would be most therapeutic?
- A. This must be very hard for you. You’re feeling worthless?'
- B. You shouldn’t feel worthless—you are still alive.'
- C. Why do you feel worthless? You still have the use of your arms.'
- D. If you attended a work rehab program you wouldn’t feel worthless.'
Correct Answer: A
Rationale: Reflecting the client’s feelings (A) validates their emotions and encourages further discussion, promoting therapeutic communication. Other options dismiss feelings (B), challenge the client inappropriately (C), or assume solutions (D).
The male client is admitted to the emergency department following a motorcycle accident. The client was not wearing a helmet and struck his head on the pavement. The nurse identifies the concept as impaired intracranial regulation. Which interventions should the emergency department nurse implement in the first five (5) minutes? Select all that apply.
- A. Stabilize the client’s neck and spine.
- B. Contact the organ procurement organization to speak with the family.
- C. Elevate the head of the bed to 70 degrees.
- D. Perform a Glasgow Coma Scale assessment.
- E. Ensure the client has a patent peripheral venous catheter in place.
- F. Check the client’s driver’s license to see if he will accept blood.
Correct Answer: A,D,E
Rationale: Stabilizing the cervical spine (A) prevents spinal injury, Glasgow Coma Scale (D) assesses neurological status, and IV access (E) prepares for interventions. Organ procurement (B) is premature, high HOB (C) risks perfusion, and checking for blood acceptance (F) is secondary.
Which client statement indicates understanding of trigeminal neuralgia management?
- A. I'll apply heat to my face for pain relief.'
- B. I'll avoid chewing on the affected side.'
- C. I'll use a hard toothbrush for oral hygiene.'
- D. I'll wash my face with cold water.'
Correct Answer: B
Rationale: Avoiding chewing on the affected side reduces pain triggers in trigeminal neuralgia.