Nokea
The nurse is caring for a patient with a C3 injury who is demonstrating diaphragmatic respirations. Which of the following findings should the nurse expect to assess?
- A. Tachypnea
- B. Hypertension
- C. Hypovolemia
- D. Hypoventilation
Correct Answer: D
Rationale: Hypoventilation almost always occurs with diaphragmatic respirations because of the decrease in vital capacity and tidal volume, which occurs as a result of impairment of the intercostal muscles.
You may also like to solve these questions
The nurse is caring for a patient who has onset Guillain-Barré syndrome. During this phase of the patient's illness, which of the following parameters is the most important for the nurse to assess?
- A. Monitor the cardiac rhythm.
- B. Determine level of consciousness.
- C. Check strength of the extremities.
- D. Observe respiratory rate and effort.
Correct Answer: D
Rationale: The most serious complication of Guillain-Barré syndrome is respiratory failure, and the nurse should monitor respiratory function continuously. The other assessments also will be included in nursing care, but they are not as important as respiratory assessment.
In which order will the nurse perform the following actions when caring for a patient with possible C6 spinal cord trauma who is admitted to the emergency department?
- A. Infuse normal saline at 150 mL/hour.
- B. Monitor cardiac rhythm and blood pressure.
- C. Administer O2 using a non-rebreather mask.
- D. Transfer the patient to radiology for spinal computed tomography (CT).
- E. Immobilize the patient's head, neck, and spine.
Correct Answer: E,C,B,A,D
Rationale: The first action should be to prevent further injury by stabilizing the patient's spinal cord. Maintenance of oxygenation by administration of 100% O2 is the second priority. Because neurogenic shock is a possible complication, monitoring of heart rhythm and BP are indicated, followed by infusing normal saline for volume replacement. A CT scan to determine the extent and level of injury is needed once initial assessment and stabilization are accomplished.
The nurse is facilitating a bladder training program for a patient who had a spinal cord injury 2 weeks ago and is stable. Which of the following amounts of daily fluid should the nurse include in the patient plan of care to maintain the patient on fluid restriction?
- A. 600-800 mL
- B. 1000-1200 mL
- C. 1400-1600 mL
- D. 1800-2000 mL
Correct Answer: D
Rationale: Many patients are maintained on fluid restriction of 1800-2000 mL/day to facilitate a bladder training program, and urinary output is monitored closely.
The nurse is caring for a patient with a neck fracture at the C5 level in the intensive care unit. During initial assessment of the patient, the nurse recognizes the presence of neurogenic shock upon assessing which of the following findings?
- A. Hypotension, bradycardia, and warm extremities
- B. Involuntary, spastic movements of the arms and legs
- C. Hyperactive reflex activity below the level of the injury
- D. Lack of movement or sensation below the level of the injury
Correct Answer: A
Rationale: Neurogenic shock is characterized by hypotension, bradycardia, and vasodilation leading to warm skin temperature. Spasticity and hyperactive reflexes do not occur at this stage of spinal cord injury. Lack of movement or sensation indicates spinal cord injury, but not neurogenic shock.
The nurse is caring for a patient who sustained a spinal cord injury a week ago and becomes angry, telling the nurse 'I want to be transferred to a hospital where the nurses know what they are doing!' Which of the following actions by the nurse is best?
- A. Ask for the patient's input into the plan for care.
- B. Clarify that abusive behaviour will not be tolerated.
- C. Reassure the patient about the competence of the nursing staff.
- D. Continue to perform care without responding to the patient's comments.
Correct Answer: A
Rationale: The patient is demonstrating behaviours consistent with the anger phase of the mourning process, and the nurse should allow expression of anger and seek the patient's input into care. Expression of anger is appropriate at this stage and should be tolerated by the nurse. Reassurance about the competency of the staff will not be helpful in responding to the patient's anger. Ignoring the patient's comments will increase the patient's anger and sense of helplessness.