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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.
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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.
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.
The nurse is caring for a young adult patient with a T3 spinal cord injury who asks the nurse about whether he will be able to be sexually active. Which of the following initial responses by the nurse is best?
- A. Reflex erections frequently occur, but orgasm may not be possible.
- B. Sildenafil is used by many patients with spinal cord injury.
- C. Multiple options are available to maintain sexuality after spinal cord injury.
- D. Penile injection, prostheses, or vacuum suction devices are possible options.
Correct Answer: C
Rationale: Although sexuality will be changed by the patient's spinal cord injury, there are options for expression of sexuality and for fertility. The other information also is correct, but the choices will depend on the degrees of injury and the patient's individual feelings about sexuality.
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.
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.