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The nurse is caring for a patient with paraplegia resulting from a T10 spinal cord injury who has a neurogenic reflex bladder. Which of the following actions should the nurse include in the plan of care?
- A. Educate on the use of the Credé method.
- B. Teach the patient how to self-catheterize.
- C. Catheterize for residual urine after voiding.
- D. Assist the patient to the toilet every 2 hours.
Correct Answer: B
Rationale: Because the patient's bladder is spastic and will empty in response to overstretching of the bladder wall, the most appropriate method is to avoid incontinence by emptying the bladder at regular intervals through intermittent catheterization. Assisting the patient to the toilet will not be helpful because the bladder will not empty. The Credé method is more appropriate for a bladder that is flaccid, such as occurs with a reflexic neurogenic bladder. Catheterization after voiding will not resolve the patient's incontinence.
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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.
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.
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 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.
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.