Nokea
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.
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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.
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.
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 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 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.