Leadership Midterm Case Study 7: Spinal Cord Injury

Mr. M is very upset and tells the nurse that he is afraid his wife will divorce him because he is "no longer a man." What is the nurse's best response at this time? 1."Have you spoken with your wife about this yet?" 2."Let me call your health care provider to talk with you about this." 3."Do you have any children with your wife?" 4."Can you tell me more so I can understand how you are feeling?"

4. "Can you tell me more so I can understand how you are feeling?"

Mr. M's care plan has a nursing concern of impaired mobility. Which actions should the RN delegate to the nursing student providing care for this client on the neurology unit? Select all that apply. 1.Administering 50 mg of IV ranitidine in 50 mL of normal saline to prevent gastric ulcers 2.Monitoring traction ropes and weights while the client is repositioned 3.Assessing the client's neurologic status for changes in movement and strength 4.Providing pin site care using hydrogen peroxide and normal saline 5.Adding a nursing concern to the care plan for the client of risk for depression 6.Checking vital signs and oxygen saturation

(Administering, pin site care, vitals) 1. Administering 50 mg of IV ranitidine in 50 mL of normal saline to prevent gastric ulcers 4. Providing pin site care using hydrogen peroxide and normal saline 6. Checking vital signs and oxygen saturation

Mr. M is experiencing incontinence. The nurse plans to establish a bladder retraining program for him. Which actions are important points for this program? Select all that apply. 1.Remove the indwelling Foley catheter. 2.Encourage the client to limit fluid intake to 1000 mL/day. 3.Gradually increase intervals between catheterizations. 4.Teach the patent to initiate voiding by tapping on his bladder every 4 hours. 5.Teach the client to perform self-catheterization if necessary. 6.Administer bethanechol chloride 20 mg orally twice a day.

(All besides limit fluid intake) 1. Remove the indwelling Foley catheter. 3. Gradually increase intervals between catheterizations. 4. Teach the patent to initiate voiding by tapping on his bladder every 4 hours. 5. Teach the client to perform self-catheterization if necessary. 6. Administer bethanechol chloride 20 mg orally twice a day.

Mr. M has stabilized and has been weaned off the ventilator. The neurologic intensive care unit nurse is to remove the ET tube. Which actions will the nurse take before removing the tube? Select all that apply. 1.Set up an oxygen delivery system. 2.Bring emergency equipment for reintubation to the bedside. 3.Hyperoxygenate the client. 4.Rapidly deflate the ET tube cuff. 5.Instruct the client to cough while the tube is removed. 6.Administer oxygen by face mask.

(Not instruct to cough or administer 02 w/ facemask) 1. Set up an oxygen delivery system. 2. Bring emergency equipment for reintubation to the bedside. 3. Hyperoxygenate the client. 4. Rapidly deflate the ET tube cuff.

Which actions should the nurse take in caring for Mr. M at this time? Select all that apply. 1.Place the client in bed in the prone position. 2.Notify the HCP. 3.Check the client's bladder for urinary retention. 4.Place an incontinence pad on the client. 5.For bladder distention, catheterize the client. 6.Monitor blood pressure and heart rate every 10 to 15 minutes.

(Not position in prone or incontinence pad) 2. Notify the HCP. 3. Check the client's bladder for urinary retention. 5. For bladder distention, catheterize the client. 6. Monitor blood pressure and heart rate every 10 to 15 minutes.

Which questions would the nurse ask the paramedics to obtain a history of the client's acute spinal cord injury (SCI)? Select all that apply. 1.What was the location and position of the client immediately after the injury? 2.Did the client experience symptoms before the injury? 3.Have any changes occurred since the injury? 4.What type of stabilization devices were used to stabilize the client? 5.Were any other persons injured at the same time at the client? 6.What treatments were given at the injury scene and en route to the ED?

(Not symptoms before injury or other persons injured) 1. What was the location and position of the client immediately after the injury? 3. Have any changes occurred since the injury? 4. What type of stabilization devices were used to stabilize the client? 6. What treatments were given at the injury scene and en route to the ED?

Which action to prevent complications associated with Mr. M's nursing concern of impaired mobility should the RN delegate to the experienced UAP? 1.Assisting with turning and repositioning the client in bed every 2 hours 2.Inspecting the client's skin for reddened areas 3.Performing range-of-motion exercises every 8 hours 4.Administering enoxaparin subcutaneously every 12 hours

1. Assisting with turning and repositioning the client in bed every 2 hours

Which instructions would the RN give the experienced UAP with regard to Mr. M's care at this time? Select all that apply. 1.Check and record vital signs every 15 minutes. 2.Use pulse oximetry to check oxygen saturation with each set of vital signs. 3.Increase oxygen flow rate by 2 L/min when oxygen saturation is more than 91%. 4.Empty the client's urinary catheter bag and record the output. 5.Teach the client how to perform coughing and deep breathing. 6.Immediately report decrease in oxygen saturation or increase in respiratory rate.

1. Check and record vital signs every 15 minutes. 2. Use pulse oximetry to check oxygen saturation with each set of vital signs. 4. Empty the client's urinary catheter bag and record the output. 6. Immediately report decrease in oxygen saturation or increase in respiratory rate.

The ED nurse assists the ED HCP in testing Mr. M's deep tendon reflexes (DTRs) which are all absent. What does the nurse suspect is the likely cause of the absent DTRs? 1.Spinal shock 2.Stabilization devices 3.Lack of oxygen to the nerves 4.Neurogenic shock

1. Spinal shock

The client's cervical injury has been immobilized with cervical tongs and traction to realign the vertebrae, facilitate bone healing, and prevent further injury. Which occurrence necessitates the nurse's immediate intervention? 1.The traction weights are resting on the floor after the client is repositioned. 2.The traction ropes are located within the pulley and are hanging freely. 3.The insertion sites for the cervical tongs are cleaned with hydrogen peroxide. 4.The client is repositioned every 2 hours by using the logrolling technique.

1. The traction weights are resting on the floor after the client is repositioned.

Mr. M is stabilized and moved to the neurologic intensive care unit with a diagnosis of SCI at level C4 to C5. As the admitting RN working with an experienced unlicensed assistive personnel (UAP), when frequent respiratory assessments are performed, which actions can the RN delegate to the UAP? Select all that apply. 1.Auscultating breath sounds every hour to detect decreased or absent ventilation 2.Ensuring that oxygen is flowing at 5 L/min via the nasal cannula 3.Teaching the client to breathe slowly and deeply and use incentive spirometry 4.Checking the client's oxygen saturation by pulse oximetry every 2 hours 5.Assessing the client's chest wall movement during respirations 6.Recording accurate intake and output

2,4,6 2. Ensuring that oxygen is flowing at 5 L/min via the nasal cannula 4. Checking the client's oxygen saturation by pulse oximetry every 2 hours 6. Recording accurate intake and output

Mr. M is to be transferred to a rehabilitation facility. Which statement indicates that the client needs additional teaching? 1."After rehabilitation, I may be able to achieve control of my bladder." 2."With rehabilitation, I will regain all of my motor functions." 3."Rehabilitation will help me to become as independent as possible." 4."After rehabilitation, I hope to return to gainful employment."

2. "With rehabilitation, I will regain all of my motor functions."

What is the nurse's priority concern during admission to the ED? 1.Spinal immobilization to prevent additional injuries to the client 2.Airway status because of interruption of spinal innervation to the respiratory muscles 3.Potential for injuries related to the client's decreased sensation 4.Dysrhythmias caused by disruption of the autonomic nervous system

2. Airway status because of interruption of spinal innervation to the respiratory muscles

The UAP reports that Mr. M's blood pressure is 178/98 mm Hg; his heart rate is 50 beats/min; he is sweating around his face, neck, and shoulders; and he reports a severe headache. What does the nurse suspect when assessing this client? 1.Spinal shock 2.Autonomic dysreflexia 3.Neurogenic shock 4.Venous thromboembolism

2. Autonomic dysreflexia

Mr. M's condition has stabilized. His cervical injury is now immobilized with a halo fixation device with jacket. He has regained the use of his arms and partial movement in his legs. Which instruction should the nurse give the UAP providing help to Mr. M in activities of daily living? 1."Feed, bathe, and dress the client so that he does not become fatigued." 2."Encourage the client to perform all of his own self-care." 3."Allow the client to do what he can and then assist with what he can't." 4."Let the client's wife do the bathing and dressing."

3. "Allow the client to do what he can and then assist with what he can't."

The nursing student asks the nurse how best to assess Mr. M's motor function. What is the nurse's best response? 1."Apply resistance while the client plantar flexes his feet." 2."Apply resistance while the client lifts his legs from the bed." 3."Apply downward pressure while the client shrugs his shoulders upward." 4."Make sure the client is able to grasp objects firmly and form a fist."

3. "Apply downward pressure while the client shrugs his shoulders upward."

An hour later, the UAP informs the RN that Mr. M's oxygen saturation has dropped to 88%, and his respirations are rapid and shallow at 34 breaths/min. On auscultation, he has decreased breath sounds bilaterally. What is the nurse's best action at this time? 1.Increase the oxygen flow to 10 L/min. 2.Suction the client's airway for oral secretions. 3.Notify the HCP immediately. 4.Call the respiratory therapist for a nonrebreather mask.

3. Notify the HCP immediately.

The nurse is caring for Mr. M when the ventilator's high-pressure alarm goes off. What intervention is the client likely to need at this time? 1. Assessment of all ventilator tubing for disconnection 2. Evaluation of the client's endotracheal (ET) tube for a cuff leak 3. Suction the client for an increased amount of secretions 4. Notification of the respiratory therapist to assess the machine

3. Suction the client for an increased amount of secretions