Nokea
The nurse is caring for a patient who has halo traction. Which of the following traction weights should the nurse anticipate being used when the traction is first applied?
- A. 1 kg
- B. 10 kg
- C. 8 kg
- D. 5.5 kg
Correct Answer: D
Rationale: The initial weight is typically 4.5-6.8 kg and thereafter approximately 2.2 kg per level with continual neurological monitoring so the only weight value within this normal range is 5.5 kg.
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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.
A patient arrives at an urgent care centre with a deep puncture wound after stepping on a nail. The patient reports having had a tetanus booster 7 years ago. Which of the following actions should the nurse anticipate?
- A. IV infusion of tetanus immune globulin (TIG)
- B. Administration of the tetanus-diphtheria (Td) booster
- C. Intradermal injection of an immune globulin test dose
- D. Initiation of the tetanus-diphtheria immunization series
Correct Answer: B
Rationale: If the patient has not been immunized within 5 years and presents with an open wound, administration of the Td booster is indicated because the wound is deep. Immune globulin administration is given by the IM route if the patient has no previous immunization. Administration of a series of immunization is not indicated. TIG is not indicated for this patient, and a test dose is not needed for immune globulin.
Which of the following actions should the nurse take when assessing a patient with trigeminal neuralgia?
- A. Examine the mouth and teeth thoroughly.
- B. Have the patient clench and relax the jaw and eyes.
- C. Identify trigger zones by lightly touching the affected side.
- D. Gently palpate the face to compare skin temperature bilaterally.
Correct Answer: A
Rationale: Oral hygiene is frequently neglected because of fear of triggering facial pain. Having the patient clench the facial muscles will not be useful because the sensory branches of the nerve are affected by trigeminal neuralgia. Light touch and palpation may be triggers for pain and should be avoided.
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.
After a young adult patient has returned home following rehabilitation for a spinal cord injury, the home care nurse notes that the partner is performing many of the activities that the patient had been managing during rehabilitation. Which of the following actions by the nurse is most appropriate at this time?
- A. Tell the partner that the patient can perform activities independently.
- B. Remind the patient about the importance of independence in daily activities.
- C. Develop a plan to increase the patient's independence in consultation with the patient and the partner.
- D. Recognize that it is important for the partner to be involved in the patient's care and support the partner's participation.
Correct Answer: C
Rationale: The best action by the nurse will be to involve all the parties in developing an optimal plan of care. Because family members who will be assisting with the patient's ongoing care need to feel that their input is important, telling the spouse that the patient can perform activities independently is not the best choice. Reminding the patient about the importance of independence may not change the behaviours of the spouse. Supporting the activities of the spouse will lead to ongoing dependency by the patient.