Nokea
The nurse is caring for a patient who had a C8 spinal cord injury 10 days ago and has a weak cough effort and loose-sounding secretions. Which of the following actions should the nurse implement initially?
- A. Suction the patient's oral and pharyngeal airway.
- B. Administer oxygen at 7-9 L/minute with a face mask.
- C. Place the hands just below the xiphoid process and push upward when the patient coughs.
- D. Encourage the patient to use an incentive spirometer every 2 hours during the day.
Correct Answer: C
Rationale: Since the cough effort is poor, the initial action should be to use assisted coughing techniques to improve the ability to mobilize secretions. The nurse places the heels of both hands just below the patient's xiphoid process and exerts firm upward pressure to the area, timed with the patient's efforts to cough. Administration of oxygen will improve oxygenation, but the data do not indicate hypoxemia. The use of the spirometer may improve respiratory status, but the patient's ability to take deep breaths is limited by the loss of intercostal muscle function. Suctioning may be needed if the patient is unable to expel secretions by coughing but should not be the nurse's first action.
You may also like to solve these questions
The nurse is caring for a patient who has an incomplete right spinal cord lesion at the level of T7, resulting in Brown-Séquard syndrome. Which of the following nursing actions should be included in the plan of care?
- A. Assessment of the patient for left leg pain
- B. Assessment of the patient for left arm weakness
- C. Positioning the patient's right leg when turning the patient
- D. Teaching the patient to look at the left leg to verify its position
Correct Answer: C
Rationale: The patient with Brown-Séquard syndrome has loss of motor function on the ipsilateral side and will require the nurse to move the right leg. Pain sensation will be lost on the patient's left leg. Left arm weakness will not be a problem for a patient with a T7 injury. The patient will retain position sense for the left leg.
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 a T1 spinal cord injury. Which of the following information should the nurse include in the teaching plan for the patient and family?
- A. Use of the shoulders will be preserved.
- B. Full function of the patient's arms will be retained.
- C. Total loss of respiratory function may occur temporarily.
- D. Elevations in heart rate are common with this type of injury.
Correct Answer: B
Rationale: The patient with a T1 injury can expect to retain full motor and sensory function of the arms. Use of only the shoulders is associated with cervical spine injury. Loss of respiratory function occurs with cervical spine injuries. Bradycardia is associated with injuries above the T6 level.
Which of the following nursing interventions is appropriate for a patient with a spinal cord injury who is in the anger phase of adjustment?
- A. Use firm kindness in all interactions.
- B. Do not allow fixation on the injury.
- C. Use simple diagrams to explain the injury.
- D. Give cheerful assistance with the activities of daily living.
Correct Answer: B
Rationale: Caring for a patient with a spinal cord injury who is in the anger phase of adjustment requires allowing the angry outbursts but not allowing fixation on the injury. Using firm kindness and giving cheerful assistance are interventions used in the depression phase. Using simple diagrams to explain the injury is useful in the first phase, shock and disbelief.
Which of the following actions should the nurse include in the plan of care for a patient who is experiencing trigeminal neuralgia?
- A. Teach facial and jaw relaxation techniques.
- B. Assess intake and output and dietary intake.
- C. Apply ice packs for no more than 20 minutes.
- D. Spend time at the bedside talking with the patient.
Correct Answer: B
Rationale: The patient with an acute episode of trigeminal neuralgia may be unwilling to eat or drink, so assessment of nutritional and hydration status is important. Because stimulation by touch is the precipitating factor for pain, relaxation of the facial muscles will not improve symptoms. Application of ice is likely to precipitate pain. The patient will not want to engage in conversation, which may precipitate attacks.