Nokea
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.
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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 facilitating a bladder training program for a patient who had a spinal cord injury 2 weeks ago and is stable. Which of the following amounts of daily fluid should the nurse include in the patient plan of care to maintain the patient on fluid restriction?
- A. 600-800 mL
- B. 1000-1200 mL
- C. 1400-1600 mL
- D. 1800-2000 mL
Correct Answer: D
Rationale: Many patients are maintained on fluid restriction of 1800-2000 mL/day to facilitate a bladder training program, and urinary output is monitored closely.
The nurse is caring for a patient who has onset Guillain-Barré syndrome. During this phase of the patient's illness, which of the following parameters is the most important for the nurse to assess?
- A. Monitor the cardiac rhythm.
- B. Determine level of consciousness.
- C. Check strength of the extremities.
- D. Observe respiratory rate and effort.
Correct Answer: D
Rationale: The most serious complication of Guillain-Barré syndrome is respiratory failure, and the nurse should monitor respiratory function continuously. The other assessments also will be included in nursing care, but they are not as important as respiratory assessment.
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.
The nurse is caring for a patient with a T2 spinal cord injury who tells the nurse, 'I feel awful today. My head is throbbing, and I feel sick to my stomach.' Which of the following actions should the nurse take first?
- A. Assess for a fecal impaction.
- B. Give the prescribed antiemetic.
- C. Check the blood pressure (BP).
- D. Notify the health care provider.
Correct Answer: C
Rationale: The BP should be assessed immediately in a patient with an injury at the T6 level or higher who complains of a headache to determine whether autonomic dysreflexia is occurring. Notification of the patient's health care provider is appropriate after the BP is obtained. Administration of an antiemetic is indicated after autonomic dysreflexia is ruled out as the cause of the nausea. The nurse may assess for a fecal impaction, but this should be done after checking the BP and lidocaine jelly should be used when performing a digital rectal exam to prevent further symptoms such as increases in the BP.