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The nurse is working in the rehabilitative setting caring for tetraplegia and paraplegia clients. When instructing family members on the difference between the sites of impairment, which location should the nurse explain differentiates the two disorders?
- A. The second cervical vertebrae
- B. The first thoracic vertebrae
- C. The seventh thoracic vertebrae
- D. The first lumbar vertebrae
Correct Answer: B
Rationale: Tetraplegia is the impairment of all extremities and the trunk when there is a spinal injury at or above the first thoracic vertebrae. Paraplegia is the impairment of all extremities below the first thoracic vertebrae.
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The nurse is caring for a client who has had intracranial surgery and is being discharged home. What instructions would the nurse give the client besides instructions on the medication?
- A. Understand that headaches are uncommon.
- B. You can cover the incision with your hair.
- C. You can expect swelling above the incision.
- D. Expect sensory changes, such as hearing a clicking sound, around the bone flap.
Correct Answer: D
Rationale: In addition, the nurse must provide the following verbal and written instructions: Watch for signs of intracranial bleeding and infection (expect swelling around the eye and below the incision). Expect sensory changes such as hearing a 'clicking' sound around the bone flap, which will disappear as healing takes place. Understand that headaches also are common, but notify the surgeon if a mild analgesic such as acetaminophen fails to relieve them. Care for the surgical site as directed by the physician. Some recommendations include keeping the incision clean, avoiding scrubbing the incision, securing remaining hair away from the incision, resuming shampooing the hair when the staples or sutures are removed, and wearing a hat when outside to avoid sunburn until hair growth resumes. Maintain safety precautions at home, including ambulating only with assistance and ensuring well-lit and clutter-free rooms. Do not drive until the risk of seizures has been eliminated. Engage in exercises that promote strength and endurance. Use techniques to ensure bowel and bladder elimination. Follow feeding and/or nutritional suggestions. Keep follow-up appointments for measuring anticonvulsant blood levels, electroencephalograms, and continued medical care and evaluation. This information is usually given to the client on a take-home instruction sheet.
The nurse is evaluating the transmission of a report from a paramedic unit to the emergency department. The medic reports that a client is unconscious with edema of the head and face and Battle sign. What clinical picture would the nurse anticipate?
- A. Edema to the head and a blackened eye
- B. Edema to the head with a large scalp laceration
- C. Edema to the head with fixed pupils
- D. Edema to the head with bruising of the mastoid process
Correct Answer: D
Rationale: Battle sign is the presence of bruising of the mastoid process behind the ear. It is not related to periorbital bleeding, lacerations, or fixed pupils.
The nurse is caring for a client immediately after a spinal cord injury. Which assessment finding is essential when caring for a client in spinal shock with injury in the lower thoracic region?
- A. Numbness and tingling
- B. Respiratory pattern
- C. Pulse and blood pressure
- D. Pain level
Correct Answer: C
Rationale: Spinal shock is a loss of sympathetic reflex activity below the level of the injury within 30 to 60 minutes after insult. In addition to the paralysis, manifestations include pronounced hypotension, bradycardia, and warm, dry skin. Numbness and tingling and pain are not as high of a concern at this time due to the cord injury. Because the level of impairment is below the first thoracic vertebrae, respiratory failure is not a concern.
The nurse is caring for a postoperative client who had surgery to decrease intracranial pressure after suffering a head injury. Which assessment finding is promptly reported to the physician?
- A. The client has periorbital edema and ecchymosis.
- B. The client's vital signs are temperature, 100.9?°F; heart rate, 88 beats/minute; respiratory rate, 18 breaths/minute; and blood pressure, 138/80 mm Hg.
- C. The client's level of consciousness has improved.
- D. The client prefers to rest in the semi-Fowler's position.
Correct Answer: B
Rationale: The assessment finding promptly reported to the physician is the information which may cause complications. It is important to report the elevation in client temperature (100.9?°F) because hyperthermia increases brain metabolism, increasing the potential for brain damage. It is not unusual for the client to experience periorbital edema and ecchymosis secondary to the head injury and surgery. Improved level of consciousness is a positive outcome of the treatment provided. There is no complication related to semi-Fowler's position.
The nurse is caring for a client who was discovered unconscious after falling off a ladder. The client is diagnosed with a concussion. All testing is normal, and discharge instructions are compiled. Which instructions have been compiled for the spouse?
- A. Acetaminophen may be administered for aches.
- B. Observe for any signs of behavioral changes.
- C. A light meal may be eaten if desired.
- D. Follow up with regular physician is encouraged.
Correct Answer: B
Rationale: All of the options are typical for a client being discharged with a concussion. The instruction that is emphasized is to observe for any signs of behavior changes, which may indicate an increase in the client's intracranial pressure. A concussion results in diffuse or microscopic injury to the brain with symptoms that may evolve.