Nokea
The nurse is caring for a patient who was admitted 24 hours previously with a C5 spinal cord injury. Which of the following nursing actions has the highest priority?
- A. Assessment of respiratory rate and depth
- B. Continuous cardiac monitoring for bradycardia.
- C. Application of pneumatic compression devices to both legs
- D. Administration of methylprednisolone infusion
Correct Answer: A
Rationale: Edema around the area of injury may lead to damage above the C4 level, so the highest priority is assessment of the patient's respiratory function. The other actions also are appropriate but are not as important as assessment of respiratory effort.
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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.
The health care provider prescribes these interventions for a patient with possible botulism poisoning. Which of the following prescriptions should the nurse question?
- A. Maintain NPO status.
- B. Obtain lumbar puncture tray.
- C. Give magnesium citrate 240 mL stat.
- D. Administer 1500 mL tap water enema.
Correct Answer: C
Rationale: Magnesium is contraindicated because it may worsen the neuromuscular blockade. The other orders are appropriate for the patient.
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.
The nurse is assessing a patient with newly diagnosed trigeminal neuralgia. Which of the following parameters should the nurse assess?
- A. Triggers that lead to facial pain
- B. Visual problems caused by ptosis
- C. Poor appetite caused by a loss of taste
- D. Weakness on the affected side of the face
Correct Answer: A
Rationale: The major clinical manifestation of trigeminal neuralgia is severe facial pain that is triggered by cutaneous stimulation of the nerve. Ptosis, loss of taste, and facial weakness are not characteristics of trigeminal neuralgia.
The nurse is caring for a patient hospitalized with Guillain-Barré syndrome who has numbness and weakness in both feet. Which of the following information should the nurse include in the patient's plan of care?
- A. Intubation and mechanical ventilation
- B. Administration of IV corticosteroid drugs
- C. Insertion of a nasogastric (NG) feeding tube
- D. IV infusion of high dose immunoglobulin (IVIG)
Correct Answer: D
Rationale: Because the Guillain-Barré syndrome is in the earliest stages (as evidenced by the symptoms), use of high-dose immunoglobulin is appropriate to reduce the extent and length of symptoms. Mechanical ventilation and tube feedings may be used later in the progression of the syndrome but are not needed now. Corticosteroid use is not helpful in reducing the duration or symptoms of the syndrome.