Nokea
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.
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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.
The nurse is caring for a patient with trigeminal neuralgia who has had a glycerol rhizotomy. Which of the following interventions should the nurse implement?
- A. Ask whether the patient is using an eye shield at night.
- B. Determine whether the patient is doing daily facial exercises.
- C. Question the patient about social activities with family and friends.
- D. Remind the patient to chew food on the unaffected side of the mouth.
Correct Answer: C
Rationale: Because withdrawal from social activities is a common manifestation of trigeminal neuralgia, asking about social activities will help in evaluating whether the patient's symptoms have improved. Glycerol rhizotomy does not damage the corneal reflex or motor functions of the trigeminal nerve, so there is no need to use an eye shield, do facial exercises, or take precautions with chewing.
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 nurse is caring for a patient with Bell's palsy who refuses to eat while others are present because of embarrassment about drooling. Which of the following responses is best for the nurse to do?
- A. Respect the patient's desire and arrange for privacy at mealtimes.
- B. Teach the patient to chew food on the unaffected side of the mouth.
- C. Offer the patient liquid nutritional supplements at frequent intervals.
- D. Discuss the patient's concerns with visitors who arrive at mealtimes.
Correct Answer: A
Rationale: The patient's desire for privacy should be respected to encourage adequate nutrition and reduce patient embarrassment. Liquid supplements will reduce the patient's enjoyment of the taste of food. It would be inappropriate for the nurse to discuss the patient's embarrassment with visitors unless the patient wishes to share this information. Chewing on the unaffected side of the mouth will enhance nutrition and enjoyment of food but will not decrease the drooling.
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.