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The nurse is developing a rehabilitation plan for a patient with a C6 spinal cord injury. Which of the following goals should the nurse include for this patient?
- A. Transfer independently to a wheelchair.
- B. Drive a car with powered hand controls.
- C. Turn and reposition independently when in bed.
- D. Push a manual wheelchair on flat, smooth surfaces.
Correct Answer: D
Rationale: The patient with a C6 injury will be able to use the hands to push a wheelchair on flat, smooth surfaces. Because flexion of the thumb and fingers is minimal, the patient will not be able to grasp a wheelchair during transfer, drive a car with powered hand controls, or turn independently in bed.
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The nurse is caring for a patient who has halo traction. Which of the following traction weights should the nurse anticipate being used when the traction is first applied?
- A. 1 kg
- B. 10 kg
- C. 8 kg
- D. 5.5 kg
Correct Answer: D
Rationale: The initial weight is typically 4.5-6.8 kg and thereafter approximately 2.2 kg per level with continual neurological monitoring so the only weight value within this normal range is 5.5 kg.
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 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 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 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.