HESI Case Study-Spinal Cord Injury

What is the best response by the nurse?

"I am sorry, but I cannot share that information with you."

Which statement by Jonathon indicates an understanding of autonomic dysreflexia?

"I should empty my bladder at least every 2 to 3 hours."

Which statement made by Jonathan's mother indicate that she understands bladder care for jonathan

"I should remove the condom catheter nightly to clean his penis."

Jonathon wants to know what a living will is. How should the nurse respond?

"It is a legal document that helps us make decisions about your healthcare, based on you wishes."

14. To evaluate the teaching, the nurse asked Ryan to explain his understanding of all instructions given. Which statements indicate Ryan's understanding? Select all that apply "It is important to drinking hot fluids prior to defecation." I will plan bowel evacuation at the same time every day." "I should empty my bladder at least every 2 to 3 hours." "Daily enemas will be needed to help achieve a bowel movement." "If I have a pounding headache, I should move to a sitting position."

"It is important to drinking hot fluids prior to defecation." Warm fluids, such as coffee or tea, can help to promote the gastrocolic reflex. This stimulates peristalsis, forcing stool toward the rectum I will plan bowel evacuation at the same time every day." Bowel care is best when scheduled at the same time every day in order to develop a habitual response. "I should empty my bladder at least every 2 to 3 hours." Autonomic dysreflexia most often occurs as a result of an overfull bladder, although it can be brought on by other noxious stimuli. It can develop suddenly, and if it is not treated promptly, it can lead to seizures, stroke, and death. Therefore, prevention is very important. "If I have a pounding headache, I should move to a sitting position." The client may be experiencing autonomic dysreflexia, an exaggerated autonomic response to a noxious stimulus resulting in hypertension and a pounding headache. Putting Ryan in a sitting position helps lower the blood pressure.

According to the principle of veracity, how should the RN respond to Jonathan's question?

"No Jonathan; it is unlikely that you will ever be able to walk again."

5. After the CT scan is complete, Ryan is transported to the MRI scan. What questions are appropriate to ask Ryan prior to beginning the procedure? select all that apply Has he ever been told he is allergic to iodine? Is he claustrophobic or afraid of closed-in, small places? When was the last time he ate or drank anything? Does he have any metal piercings on his body or metal implants? Does he have any allergies to eggs

- Is he claustrophobic or afraid of closed-in, small places? - Does he have any metal piercings on his body or metal implants?

4. Ryan is scheduled to have an open CT scan with contrast procedure. What questions should be asked prior to administering intravenous contrast to Ryan's saline lock? Select all that apply What happens when he eats shellfish (crustaceans)? Has he ever been allergic to peanuts? Does he have an allergy to iodine? Does he have any metal piercings on his body or metal implants?

- What happens when he eats shellfish (crustaceans) Studies have shown a correlation between shellfish allergies and an allergic reaction to the contrast used in CT scan procedures. - Does he have an allergy to iodine The contrast that is used for CT scan procedures contains iodine.

Which intervention(s) should the RN implement to address this concern? (Select all)

-Allow Jonathan to watch television as much as he likes -Encourage Jonathan's girlfriend to talk to him during visits -Provide Jonathan prism glasses, and tell him how to use them

What medication(s) should the ED RN expect the HCP to prescribe for Jonathan? (Select all)

-Methylprednisolone sodium succinate, a corticosteriod -Dopamine, a vasopressor

1. What should Ryan's friends do while waiting for emergency personnel to arrive? Select all that apply Help Ryan move his legs and assist him to sit up. Place a blanket over Ryan and make sure no one moves him. Attempt to stabilize his neck with any type of soft material. Carefully put Ryan in the back of a truck with one man holding his neck. Ensure that the scene around Ryan is safe and that he is not in any immediate danger.

-Place blanket over Ryan and make sure no one moves him. Any movement or improper handling could cause further damage and loss of neurological function. -Ensure that the scene around Jonathan is safe and that he is not in any immediate danger. Ensuring that the scene is safe and protecting Ryan from any immediate danger is important.

6. Which assessment data warrants immediate intervention by the ED RN? (Select all) Ryan complains of a loss of sensation and reflexes below his elbows. His skin is flushed and his extremities are warm to touch. Ryan is not able to demonstrate deep breaths when asked to breathe in deep and cough. Ryan's respirations are 20 breaths/min and he is talking without difficulty. Ryan's blood pressure is 80/45 mmHg and his pulse is 48 beats/min. Ryan appears to have bladder distention.

-Ryan complains of a loss of sensation below his shoulders. His skin is flushed and warm to touch, particularly in the extremities A loss of sensation and reflexes below the waist is a sign of spinal shock. Signs of vasodilation and warmth of skin below the level of injury, and pooling of venous return in the periphery, are signs of neurogenic shock. -Ryan's blood pressure is 80/45, and his pulse is 48 Hypotension and bradycardia are signs of neurogenic shock. This is a medical emergency that warrants immediate intervention. -Ryan appears to have bladder distention Due to the spinal cord injury resulting in spinal shock, bladder paralysis is causing urinary retention, which needs to be addressed. An order for placement of indwelling catheter needs to be initiated.

Methylprednisolone Sodium Succinate (Solu-Medrol), is prescribed as 125 mg intravenous piggy back (IVPB) over 30 minutes. The IVPB containing the medication contains 100 mL of fluid. The drop factor on the IV tubing is10 gtts/min. How many drops/min (gtts/min) should the nurse regulate the IVPB? (If applicable, round to the whole number)

33

12. Which intervention should the nurse implement? Reassure Ryan that everything will be fine and encourage him not to think like that. Encourage Ryan to talk to the chaplain about his feelings as soon as possible. Request the hospital ethics committee to meet and discuss Ryan's wishes. Arrange a meeting with Ryan, his family, and the healthcare team to discuss Ryan's concerns.

Arrange a meeting with Ryan, his family, and the healthcare team to discuss Ryan's concerns. Client advocacy is a priority for the nurse. Actively advocating for clients who are vulnerable or unable to promote their own needs is the correct ethical action to implement. Additionally, such a meeting can facilitate open communication among all of the parties involved and any misconceptions can be discussed.

Which intervention should the RN implement first?

Ask Jonathan if he would like to share his fears about life after leaving the hospital

3. Which intervention has highest priority when assessing Ryan?

Assess Ryan's breathing pattern and his ability to coug.h. Since a cervical spinal cord injury is suspected, the nurse must be aware that edema may ascend the spinal cord, which can compromise breathing and coughing. Breathing is always the priority, especially when there is the possibility that oxygenation might be impaired.

8. Which nursing intervention is included in the care plan when managing a client with Gardner-Wells tongs? Do not remove the traction weights and ensure they hang freely. Ensure that an extra set of drill bits are available in case a new set of predrilled holes must be made in Ryan's skull. Place the velcro binders securely around Ryan's head. Apply a halo vest when Ryan is in the upright position.

Do not remove the traction weights and ensure they hang freely. Traction is applied to the tongs by employing weights to maintain alignment. Removing the weights would result in misalignment, possibly creating further damage. Weights should hang freely so they do not interfere with the traction. Ryan should also be assessed for evidence of infection at the spring-loaded pin sites.

Keeping the head, neck, and spinal column in a neutral position, the paramedics and the nurse apply a cervical collar. A large bore IV is started, and oxygen is applied at 8 L/min using nasal prongs. Ryan is transported to the trauma center via ambulance. The healthcare provider (HCP) requests the following diagnostic labs: Complete blood count (CBC).Urinalysis (UA).Serum electrolytes.Type and screen blood.Amylase & lactate.Toxicology screen.Liver function tests. Previous Section

Health Promotion and Maintenance Based on the description of Ryan's limited physical movement after the accident, the nurse suspects that Ryan has experienced a spinal cord injury involving the lower cervical region.

Which area has priority according to Maslow's heirarchy of needs

Instructions concerning ways to prevent urinary tract infections

Which psychosocial intervention by the nurse has priority at this time?

Let Jonathan know that if he wants to talk or has questions, the RN is available to listen

Which task can the nurse delegate to the UAP?

Measure the intake and output for the client taking diuretics

Which intervention should the nurse implement first?

Move Jonathan to a sitting position

7. What intervention should the nurse implement first? Assess Ryan for symptoms of paralytic ileus. Notify the ED HCP immediately. Assist the ED HCP in inserting an endotracheal tube. Prepare to administer the vasoconstrictor dopamine.

Notify the ED healthcare provider (HCP) immediately. This is a medical emergency. The neurogenic shock must be addressed immediately due to the effects of the hypotension and bradycardia. Spinal shock is the complete loss of all reflex, motor, sensory, and autonomic activity below the lesion. It is also imperative to initiate medical interventions to hopefully lessen the severity of the injury.

9. Which intervention should be implemented for a paralytic ileus? Encourage Ryan to eat a high-calorie, high-fiber diet. Turn Ryan every 2 hours in the kinetic bed. Obtain an order to insert a nasogastric tube and set the siphon drainage to a low, intermittent suction. Continue to assess Ryan, but take no action at this time.

Obtain an order to insert a nasogastric tube and set the siphon drainage to a low, intermittent suction A nasogastric tube is inserted to relieve distention and prevent aspiration.

What is the best initial action by the nurse?

Obtain more information about what the grandfather want to do

Which intervention should the nurse implement to address disuse syndrome?

Perform passive range of motion (ROM) exercises every 4 hours

Which intervention will the RN include when discussing ways to prevent muscle spasticity

Perform stretching exercises five to seven times each day

2. If respiratory compromise occurs, what action should the nurse take to keep the airway open without compromising Ryan's spine further? Logroll to side while maintaining neutral alignment. Perform the jaw-thrust technique. Flex the neck with a wedge pillow. Use the chin-lift/head-tilt technique.

Perform the jaw-thrust technique The jaw-thrust is the safest first approach to opening the airway of a client who has a suspected neck injury because in most cases it can be accomplished without extending the neck.

Which action should RN implement

Refer Jonathan to a local counselor for vocational rehabilitation

10. Which nursing diagnosis has priority at this time? Self-care deficit. Disturbed sensory perception. Risk for impaired skin integrity. Risk for ineffective coping.

Risk for impaired skin integrity. Immobility always increases the client's risk for impaired skin integrity. Skin sores are the most common and devastating complication of spinal cord injury. Maslow's Hierarchy of Needs addresses physiological needs first.

13. What action should the nurse implement at this time? Allow Ryan's mother to cry and do not disturb her. Ask the hospital chaplain to come and see Ryan's mother. Sit down beside Ryan's mother. Discuss this situation with Ryan as soon as possible.

Sit down beside Ryan's mother Offering a caring, supportive presence to Ryan's mother is the priority intervention at this time. It provides an opportunity for Ryan's mother to share her feelings, if she desires to do so.

How should the nurse respond to this statement?

Sit quietly and allow the grandfather to continue

Which behavior by the UAP warrants immediate intervention by the RN?

The UAP is feeding the client

11. Which outcome should the RN use for evaluation of the efficacy of interventions designed for this nursing diagnosis? The client's family inspects the skin for reddened areas daily. The client exhibits no reddened areas or breaks in the skin. The nursing staff rotates the client's kinetic bed per unit protocol. The physical therapist performs passive range of motion exercises. Submit Previous Section

The client exhibits no reddened areas or breaks in the skin

Which member of the rehab multidisciplinary team is responsible for ensuring that Jonathan will be discharged to a home that is equipped with care for him?

The occupational therapist

Case Conclusion Ryan is discharged to his parent's home after the house is evaluated and minor changes are made. The house is now equipped with a ramp, and what was once the dining room will now be Ryan's bedroom. Someone from home health services is scheduled to visit Ryan daily, and his mother and his girlfriend will work together to provide care for Ryan. His significant others have verbalized and accurately demonstrated the care Ryan will need when he is discharged home.

impaired Gas Exchange, r/t diaphragmatic gatifue or paralysis and retained secreaions as manifested by decreased PaO2 content, increased PaCO2 fatigue, diminished breath sounds