Nokea
The nurse suspects that a newly admitted client is in spinal shock. What is a symptom(s) of spinal shock? Select all that apply.
- A. Bladder distention
- B. Poikilothermia
- C. Loss of hunger sensation
- D. Circulatory failure
- E. No perspiration below the level of the injury
Correct Answer: A,B,E
Rationale: In addition to paralysis, manifestations include pronounced hypotension, bradycardia, and warm, dry skin. If the level of injury is in the cervical or upper thoracic region, respiratory failure can occur. Bowel and bladder distention develop. The client does not perspire below the level of injury, which impairs temperature control. The client manifests with poikilothermia, body temperature of the environment. Symptoms of spinal shock do not include loss of hunger sensation or circulatory failure.
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A client has sustained a head injury and is unconscious in the emergency room. A family member of the client arrives and is providing details of the client's medical history. Which information is of most concern to the nurse?
- A. The client is a heart transplant recipient.
- B. The client's medications include warfarin (Coumadin).
- C. The client is HIV positive.
- D. The client has a history of concussions from playing hockey.
Correct Answer: B
Rationale: The nurse is most concerned that the client is prescribed warfarin (Coumadin) because this is a blood thinner. Due to the action of the medication, the client is at a high risk for intracranial bleeding. The cardiovascular system will be assessed, but that is not the area of greatest concern at this time. The nurse will care for the HIV positive client using standard precautions. A history of concussions may indicate past brain damage, but the potential for active bleeding is the highest concern.
The nurse is admitting a client from the emergency department with a reported spinal cord injury. What device would the nurse expect to be used to provide correct vertebral alignment and to increase the space between the vertebrae in a client with spinal cord injury?
- A. Cervical collar
- B. Cast
- C. Traction with weights and pulleys
- D. Turning frame
Correct Answer: C
Rationale: Traction with weights and pulleys is applied to provide correct vertebral alignment and to increase the space between the vertebrae. A cast and a cervical collar are used to immobilize the injured portion of the spine. A turning frame is used to change the client's position without altering the alignment of the spine.
The nurse learns a client was reported to have a history of basilar skull fracture with otorrhea. What assessment finding does the nurse anticipate?
- A. The client has cerebral spinal fluid (CSF) leaking from the ear.
- B. The client has ecchymosis in the periorbital region.
- C. The client has an elevated temperature.
- D. The client has serous drainage from the nose.
Correct Answer: A
Rationale: Otorrhea means leakage of CSF from the ear. The client with a basilar skull fracture can create a pathway from the brain to the middle ear due to a tear in the dura. As a result, the client can have cerebral spinal fluid leak from the ear. The nurse may assess clear fluid in the ear canal. Ecchymosis and periorbital edema can be present as a manifestation of bruising from the head injury. An elevated temperature may occur from the head injury and is monitored closely. The client may have serous drainage from the nose especially immediately following the injury.
A middle-aged client has scheduled a sick visit to the physician's office, reporting symptoms of lower back pain with exacerbation upon movement. The nurse draws a picture of the components of the spinal cord and surrounding structures and shows potential causes of the pain. Which area of the drawing would the nurse emphasize?
- A. Spinal cord pathway
- B. Nucleus pulposus
- C. Bony vertebrae
- D. Associated musculature
Correct Answer: B
Rationale: Pressure on the spinal nerve roots result from trauma, herniated disks, and tumors. The nurse would emphasize the nucleus pulposus as a common area of problem. Stress caused by poor body mechanics, age, or disease weakens an area in the vertebra, causing the spongy center of the vertebra, the nucleus pulposus, to swell and herniate. The spinal cord pathway can cause symptoms of numbness and tingling. The bony vertebrae can present symptoms when fractures and bony fragments occur. Associated musculature pulling can place the vertebrae out of alignment causing symptoms.
The nurse is caring for a client who requires spine surgery to remove bone fragments and fuse the vertebrae. From which location will bone be taken for the fusion?
- A. Iliac crest
- B. Floating rib
- C. Femur
- D. Mandible
Correct Answer: A
Rationale: To fuse the vertebrae during surgery, the physician uses bone from the iliac crest. The other options are incorrect.