Case Study 7: Spinal Cord Injury

Mr. M is a 32 year old man brought to the ED by paramedics after a fall from the second story roof of his home. He was placed on a spinal board with a cervical collar to immobilize his spine. After spinal radiographs are obtained, the HCP determines that he has a vertebral compression injury at the C4 to C5 level.

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The HCP prescribes that Mr. M receive endotracheal intubation and be placed on mechanical ventilation; his O2 increases to 96%, and his RR decrease to 18 (10 ventilator breaths per minute). On auscultation, he has breath sounds present in all lung lobes bilaterally

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11. Which action to prevent complications associated with Mr. M's nursing concern of impaired mobility andould the RN delegate to the experienced UIAP? a. Assisting with turning and repositioning the client in bed every 2 hours b. Inspecting The client's skin for reddened areas c. Performing ROM exercises Q8H d. Administering enoxaparin SQ Q12H

A

13. The UAP reports that Mr. M's BP is 178/98, HR 50, he is sweating around his face, neck, and shoulders; and he reports a severe headache. What does the nurse suspect when assessing this client? a. Spinal shock b. Autonomic dysreflexia c. Neurogenic shock d. Venous thromboembolism

B

18. Mr. M is to be transferred to a rehab facility. Which statement indicates that the client needs additional teaching? a. "After rehab, I may be able to achieve control of my bladder." b. "With rehab, I will regain all of my motor functions" c. "Rehab will help me to become as independent as possible" d. "AFter rehab, I hope to return to gainful employment."

B

2. What is the nurse's priority concern during admission to the ED? a. Spinal immobilization to prevent additional injuries to the client b. Airway status because of interruption of spinal innervation to the respiratory muscles c. Potential for injuries related to the client's decreased sensation d. Dysrhythmias caused by disruption of the ANS

B

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

B, C, E, F

3. 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? a. Spinal shock b. Stabilization devices c. Lack of oxygen to the nerves d. Neurogenic shock

A

9. 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 a. The traction weights are resting on the floor after the client is repositioned b. The traction ropes are located within the pulley and are hanging freely c. The insertion sites for the cervical tongs are cleaned with hydrogen peroxide d. The client is repositioned every 2 hours by using the logrolling technique

A

8. Mr. M has stabilized and has been weaned off the ventilator. The neurologic ICU nurse is to remove the ET tube. Which action will the nurse take before removing the tube? Select all that apply a. Set up an O2 delivery system b. Bring emergency equipment for reintubation to the bedside c. Hyperoxygenate the patient d. Rapidly deflate the ET tube cuff e. Instruct the client to cough while the tube is removed f. Administer o2 by face mask

A, B, C, D

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

A, B, D, F

17. 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 a. Remove indwelling Foley catheter b. Encourage the client to limit fluid intake to 1000 mL/day c. Gradually increase intervals between catheterizations d. Teach the patient to initiate voiding by tapping on his bladder every 4 hours e. Teach the client to perform self-catheterization if necessary f. Administer bethanechol chloride 20 mg orally twice a day

A, C, D, E, F

1. Which questions would the nurse ask the paramedics to obtain a history of the client's acute spinal cord injury? Select all that apply a. What was the location and position of the client immediately after the injury? b. Did the client experience symptoms before the injury? c. Have any changed occurred since the injury? d. What type of stabilization devices were used to stabilize the patient? e. Were any other persons injured at the same time as the client? f. What treatments were given at the injury scene and en route to the ED?

A, C, D, F

10. 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 neuro unit? Select all that apply a. Adminsitering 50 mg of IV ranitidine in 50 mL of normal saline to prevent gastric ulcers b. Monitoring traction ropes and weights while the client is repositioned c. Assessing the clients neuro status for changes in movement and strength d. Providing pin site carte using hydrogen peroxide and normal saline e. Adding a nursing concern to the care plan for the client of risk for depression f. Checking vital signs and o2 sat

A, D, F

7. 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? a. Assessment of all ventilator tubing for disconnection b. Evaluation of the client's Et tube for a cuff leak c. Suction the client for an increased amount of secretions d. Notification of the respiratory therapist to assess the machine

C

4. 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 del-egate to the UAP? Select all that apply a. Auscultating breath sounds every hour to detect decreased or absent ventilation b. Ensuring that oxygen is flowing at 5 L/min via nasal cannula c. Teaching the client to breathe slowly and use IS d. Checking the client's oxygen saturation by pulse sensation Q2H e. Assessing the client's chest wall movement during respirations f. Recording accurate intake and output

B, D, F

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

C

15. "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?" a. "Feed, bathe, and dress the client so that he does not become fatigued." b. "Encourage the client to perform all of his own self-care." c. "Allow the client to do what he can then assist with what he can't do." d. "Let the client's wife do the bathing and dressing."

C

5. 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? a. Increase the oxygen flow to 10 L/min b. Suction the client's airway for oral secretions c. Notify the HCP immediately d. Call the respiratory therapist for a non rebreather mask

C

16. 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? a. "Have you spoken with your wife about this yet?" b. "Let me call your healthcare provider to talk with you about this." c. "Do you have any children with your wife?" d. "Can you tell me more so I can understand how you are feeling?"

D