Nokea
The nurse is caring for a client who has undergone cervical laminectomy surgery. Which nursing intervention(s) is included in the postoperative plan of care? Select all that apply.
- A. Monitor vital signs.
- B. Report an inability to void or an output of less than 8 oz (240 mL) in 8 hours.
- C. Instruct on coughing and deep breathing exercises.
- D. Perform side-to-side range-of-motion exercises of the head and neck.
- E. Perform a neurovascular assessment below the area of the surgery.
- F. Examine dressing for CSF leakage or bleeding.
Correct Answer: A,B,E,F
Rationale: When planning care for a client who has undergone surgery for cervical nerve root decompression, the nurse should include monitoring vital signs, reporting on fluid intake and output, instruction on deep breathing exercises, performing neurovascular assessment below the area of the surgery, and examining the dressing for CSF leakage or bleeding. The nurse should not have the client perform coughing exercises, because these increase pressure within the spinal canal. The nurse should instruct the client to avoid side-to-side rotation of the head for the client with cervical nerve compression and should not perform side-to-side range of motion exercises of the head and neck.
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The nurse is caring for a client immediately after a spinal cord injury. Which assessment finding is essential when caring for a client in spinal shock with injury in the lower thoracic region?
- A. Numbness and tingling
- B. Respiratory pattern
- C. Pulse and blood pressure
- D. Pain level
Correct Answer: C
Rationale: Spinal shock is a loss of sympathetic reflex activity below the level of the injury within 30 to 60 minutes after insult. In addition to the paralysis, manifestations include pronounced hypotension, bradycardia, and warm, dry skin. Numbness and tingling and pain are not as high of a concern at this time due to the cord injury. Because the level of impairment is below the first thoracic vertebrae, respiratory failure is not a concern.
The nurse is caring for a client with paralysis as a result of a spinal cord injury. When planning care related to the musculoskeletal system, which immediate complication(s) should the nurse consider? Select all that apply.
- A. Calcium depletion
- B. Contractures
- C. Respiratory arrest
- D. Spinal shock
- E. Autonomic dysreflexia
Correct Answer: C,D
Rationale: Spinal shock is an immediate complication of spinal cord injury, and is characterized by immediate loss of all cord functions below the point of injury. When planning care for clients with a spinal cord injury, the nurse should consider immediate complications including respiratory arrest and spinal shock. Calcium depletion, contractures, and autonomic dysreflexia are all long-term complications of spinal cord injury leading to paralysis.
The nurse learns a client was reported to have a history of basilar skull fracture with otorrhea. What assessment finding does the nurse anticipate?
- A. The client has cerebral spinal fluid (CSF) leaking from the ear.
- B. The client has ecchymosis in the periorbital region.
- C. The client has an elevated temperature.
- D. The client has serous drainage from the nose.
Correct Answer: A
Rationale: Otorrhea means leakage of CSF from the ear. The client with a basilar skull fracture can create a pathway from the brain to the middle ear due to a tear in the dura. As a result, the client can have cerebral spinal fluid leak from the ear. The nurse may assess clear fluid in the ear canal. Ecchymosis and periorbital edema can be present as a manifestation of bruising from the head injury. An elevated temperature may occur from the head injury and is monitored closely. The client may have serous drainage from the nose especially immediately following the injury.
The nurse is caring for a client with impaired physical mobility who has been hospitalized. What nursing intervention helps reduce the potential for formation of thrombi and renal calculi in this client?
- A. Provide a well-balanced diet.
- B. Position the client.
- C. Keep the client hydrated.
- D. Help the client perform exercises.
Correct Answer: C
Rationale: The nurse should keep the client hydrated. Adequate hydration reduces the potential for the formation of thrombi and renal calculi. A well-balanced diet provides nutrients and elements necessary for energy and to sustain cellular growth and repair. Positioning the client helps avoid joint contractures and foot drop. Active and passive exercise maintains joint flexibility and reduces muscle atrophy and atony.
A 6-year-old child has come to the emergency department (ED) after falling off a bike. The health care provider diagnoses a concussion and the child's parent asks the nurse what a concussion is. What should the nurse's response be?
- A. A concussion is a blow to the head that bruises the brain.
- B. A concussion is a blow to the head that is hard enough for the brain to bounce off the other side of the skull.
- C. A concussion is a blow to the head that is minor and has no real consequences.
- D. A concussion is a blow to the head that jars the brain, resulting in diffuse and microscopic injury to the brain.
Correct Answer: D
Rationale: A concussion results from a blow to the head that jars the brain. It usually is a consequence of falling, striking the head against a hard surface such as a windshield, colliding with another person (e.g., between athletes), battering during boxing, or being a victim of violence. A concussion results in diffuse and microscopic injury to the brain. The other options are incorrect because they give incorrect information to the mother.