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When the nurse observes a patient experiencing a severe episode of autonomic dysreflexia, what should be the initial intervention?
- A. Locate the cause of irritation.
- B. Assess the blood pressure.
- C. Cover the patient with several blankets.
- D. Raise the head of the bed to a high Fowler's position.
Correct Answer: D
Rationale: The head of the bed should be raised immediately. Raising the head of the bed will reduce the blood pressure. Finding the cause of the episode is secondary to preventing the possibility of a stroke from the hypertension.
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The nurse recognizes that the rehabilitation process involves the efforts of various disciplines. The focus of rehabilitation is to build on which area?
- A. A person's losses
- B. A person's long-term plans
- C. A person's drives
- D. A person's abilities
Correct Answer: D
Rationale: The underlying philosophy of rehabilitation is to focus on the abilities of the patient.
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.
When speaking to a group of high school students, the rehabilitation nurse states that spinal cord injuries resulting in paralysis occur mainly as the result of traumatic accidents in which group of individuals?
- A. Middle-aged men
- B. Older adult females
- C. Young males
- D. Young females
Correct Answer: C
Rationale: Individuals paralyzed by spinal cord injuries are primarily young males.
The patient with a brain injury is beginning to regain memory. The nurse explains to the family that what will most likely occur?
- A. The patient will become less combative.
- B. The patient will become angrier.
- C. The patient will become more depressed.
- D. The patient will wish to retire.
Correct Answer: C
Rationale: Generally, the more the memory improves, the more the patient becomes depressed.
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.