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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.
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The nurse is caring for a client who was discovered unconscious after falling off a ladder. The client is diagnosed with a concussion. All testing is normal, and discharge instructions are compiled. Which instructions have been compiled for the spouse?
- A. Acetaminophen may be administered for aches.
- B. Observe for any signs of behavioral changes.
- C. A light meal may be eaten if desired.
- D. Follow up with regular physician is encouraged.
Correct Answer: B
Rationale: All of the options are typical for a client being discharged with a concussion. The instruction that is emphasized is to observe for any signs of behavior changes, which may indicate an increase in the client's intracranial pressure. A concussion results in diffuse or microscopic injury to the brain with symptoms that may evolve.
The nurse suspects that a newly admitted client is in spinal shock. What is a symptom(s) of spinal shock? Select all that apply.
- A. Bladder distention
- B. Poikilothermia
- C. Loss of hunger sensation
- D. Circulatory failure
- E. No perspiration below the level of the injury
Correct Answer: A,B,E
Rationale: In addition to paralysis, manifestations include pronounced hypotension, bradycardia, and warm, dry skin. If the level of injury is in the cervical or upper thoracic region, respiratory failure can occur. Bowel and bladder distention develop. The client does not perspire below the level of injury, which impairs temperature control. The client manifests with poikilothermia, body temperature of the environment. Symptoms of spinal shock do not include loss of hunger sensation or circulatory failure.
The nursing instructor is teaching about hematomas to a pre-nursing pathophysiology class. What would the nursing instructor describe as an arterial bleed with rapid neurologic deterioration?
- A. Extradural hematoma
- B. Epidural hematoma
- C. Subdural hematoma
- D. Intracranial hematoma
Correct Answer: B
Rationale: An epidural hematoma stems from arterial bleeding, usually from the middle meningeal artery, and blood accumulation above the dura. It is characterized by rapidly progressive neurologic deterioration.
The nurse is admitting a client from the emergency department with a reported spinal cord injury. What device would the nurse expect to be used to provide correct vertebral alignment and to increase the space between the vertebrae in a client with spinal cord injury?
- A. Cervical collar
- B. Cast
- C. Traction with weights and pulleys
- D. Turning frame
Correct Answer: C
Rationale: Traction with weights and pulleys is applied to provide correct vertebral alignment and to increase the space between the vertebrae. A cast and a cervical collar are used to immobilize the injured portion of the spine. A turning frame is used to change the client's position without altering the alignment of the spine.
The intensive care unit has four clients received from a violent motor vehicle accident. Which client would the nurse assess first?
- A. The client with an open head injury
- B. The client with a basilar fracture
- C. The client with a concussion
- D. The client with a coup injury
Correct Answer: B
Rationale: Of the four clients, the client whom the nurse would assess first would be the client with a basilar fracture due to location of the fracture being at the base of the skull. This location is especially dangerous because it can cause edema of the brain near the spinal cord and can interfere with circulation of cerebral spinal fluid. An open head injury causes a potential for infection but are less likely to have an increased intracranial pressure. A concussion is a blow to the head that jars the brain. A coup injury occurs when the brain is struck directly.