Nokea
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.
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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 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 was admitted 24 hours previously with a C5 spinal cord injury. Which of the following nursing actions has the highest priority?
- A. Assessment of respiratory rate and depth
- B. Continuous cardiac monitoring for bradycardia.
- C. Application of pneumatic compression devices to both legs
- D. Administration of methylprednisolone infusion
Correct Answer: A
Rationale: Edema around the area of injury may lead to damage above the C4 level, so the highest priority is assessment of the patient's respiratory function. The other actions also are appropriate but are not as important as assessment of respiratory effort.
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.
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.