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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.
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The nurse is caring for a patient with Bell's palsy who refuses to eat while others are present because of embarrassment about drooling. Which of the following responses is best for the nurse to do?
- A. Respect the patient's desire and arrange for privacy at mealtimes.
- B. Teach the patient to chew food on the unaffected side of the mouth.
- C. Offer the patient liquid nutritional supplements at frequent intervals.
- D. Discuss the patient's concerns with visitors who arrive at mealtimes.
Correct Answer: A
Rationale: The patient's desire for privacy should be respected to encourage adequate nutrition and reduce patient embarrassment. Liquid supplements will reduce the patient's enjoyment of the taste of food. It would be inappropriate for the nurse to discuss the patient's embarrassment with visitors unless the patient wishes to share this information. Chewing on the unaffected side of the mouth will enhance nutrition and enjoyment of food but will not decrease the drooling.
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.
The nurse is caring for a patient who had a C8 spinal cord injury 10 days ago and has a weak cough effort and loose-sounding secretions. Which of the following actions should the nurse implement initially?
- A. Suction the patient's oral and pharyngeal airway.
- B. Administer oxygen at 7-9 L/minute with a face mask.
- C. Place the hands just below the xiphoid process and push upward when the patient coughs.
- D. Encourage the patient to use an incentive spirometer every 2 hours during the day.
Correct Answer: C
Rationale: Since the cough effort is poor, the initial action should be to use assisted coughing techniques to improve the ability to mobilize secretions. The nurse places the heels of both hands just below the patient's xiphoid process and exerts firm upward pressure to the area, timed with the patient's efforts to cough. Administration of oxygen will improve oxygenation, but the data do not indicate hypoxemia. The use of the spirometer may improve respiratory status, but the patient's ability to take deep breaths is limited by the loss of intercostal muscle function. Suctioning may be needed if the patient is unable to expel secretions by coughing but should not be the nurse's first action.
The nurse is caring for a patient with a neck fracture at the C5 level in the intensive care unit. During initial assessment of the patient, the nurse recognizes the presence of neurogenic shock upon assessing which of the following findings?
- A. Hypotension, bradycardia, and warm extremities
- B. Involuntary, spastic movements of the arms and legs
- C. Hyperactive reflex activity below the level of the injury
- D. Lack of movement or sensation below the level of the injury
Correct Answer: A
Rationale: Neurogenic shock is characterized by hypotension, bradycardia, and vasodilation leading to warm skin temperature. Spasticity and hyperactive reflexes do not occur at this stage of spinal cord injury. Lack of movement or sensation indicates spinal cord injury, but not neurogenic shock.
Which of the following nursing interventions is appropriate for a patient with a spinal cord injury who is in the anger phase of adjustment?
- A. Use firm kindness in all interactions.
- B. Do not allow fixation on the injury.
- C. Use simple diagrams to explain the injury.
- D. Give cheerful assistance with the activities of daily living.
Correct Answer: B
Rationale: Caring for a patient with a spinal cord injury who is in the anger phase of adjustment requires allowing the angry outbursts but not allowing fixation on the injury. Using firm kindness and giving cheerful assistance are interventions used in the depression phase. Using simple diagrams to explain the injury is useful in the first phase, shock and disbelief.