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What should a nurse explain to a patient as a cause of triggering autonomic dysreflexia?
- A. Loud sound
- B. Distended bladder
- C. Leg cramp
- D. Sudden chilling
Correct Answer: B
Rationale: Patients with spinal cord lesions above T5 may experience sudden and extreme elevations in blood pressure caused by a reflex action of the autonomic nervous system. It is produced by stimulation of the body below the level of the injury, usually by a distended bladder from a blocked catheter. Any stimulation can produce the syndrome, including constipation, diarrhea, sexual activity, pressure injuries, position changes (from lying to sitting), and even wrinkles in clothing or bed sheets.
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When changing the position of a patient with a spinal cord injury at T4, the nurse should recognize that what symptom is an indication of an episode of autonomic dysreflexia?
- A. Nausea
- B. Pallor
- C. Goose bumps
- D. Dizziness
Correct Answer: C
Rationale: Patients with spinal cord lesions above T5 may experience sudden and extreme elevations in blood pressure caused by a reflex action of the autonomic nervous system. It is produced by stimulation of the body below the level of the injury, usually by a distended bladder from a blocked catheter. Any stimulation can produce the syndrome, including constipation, diarrhea, sexual activity, pressure injuries, position changes (from lying to sitting), and even wrinkles in clothing or bed sheets. Other symptoms may include diaphoresis, shivering, goose bumps, flushing of the skin, and a severe pounding headache.
Following admission, how soon must a comprehensive rehabilitation plan of care be implemented on a rehabilitation patient?
- A. 12 hours
- B. 24 hours
- C. 3 days
- D. 1 week
Correct Answer: B
Rationale: A comprehensive rehabilitation plan must be initiated within 24 hours of admission to the rehabilitation service. The results of the interdisciplinary assessment provide the basis for development of the plan of care. The team has 3 days from admission to review and revise the plan of care.
The nurse should tell a paraplegic that the rehabilitation experience will consist of:
- A. relearning former skills.
- B. learning to walk.
- C. learning new skills to adapt to a different lifestyle.
- D. developing muscle strength.
Correct Answer: C
Rationale: The type and the focus of rehabilitation are individualized to the patient, the injury, and abilities. Skills will be taught to enhance the patient's adaptation to a new lifestyle.
The nurse is caring for a victim of posttraumatic stress syndrome. The nurse identifies which techniques as examples of therapeutic communication?
- A. Listening
- B. Reframing
- C. Characterizing
- D. Normalizing responses
- E. Working to develop trust
Correct Answer: A,B,D,E
Rationale: The techniques of therapeutic communication that are important to use with the PTSD patient are listening, reframing, normalizing responses, and working to develop trust.
The nurse who is engaged in gerontological rehabilitation nursing has a dual challenge. The gerontological rehabilitation nurse must assess not only the debilitating factors of disease but also which other factor?
- A. Advancing age
- B. Reduced ability to learn
- C. Limited energy
- D. Eroded interest level
Correct Answer: A
Rationale: Gerontological rehabilitation nursing focuses on the unique requirements of older adult rehabilitation. The elderly, with their potential physical limitations, require specialized care.