Med-Surg Ch. 43

The nurse is teaching a patient and her husband about sexuality issues after a spinal cord injury. Which comment by the patient indicates a correct understanding of the nurse's instruction?

'I may still be able to get pregnant.'

The nurse is providing instructions to a client with a spinal cord injury about caring for the halo device. The nurse plans to include which instructions?

"Keep straws available for drinking fluids."

Which patient statement indicates that self-care for a halo fixation device had been effective?

'I will not drive until the device is removed.'

The nurse is preparing to perform an intermittent urinary catheterization on a patient with a spinal cord injury. The patient reports a sudden onset of headache along with nausea and sweating, and the nurse assesses a blood pressure of 185/110 mm Hg. What is the best action by the nurse?

Elevate the head of the bed to an upright position

Which mechanism of spinal cord injury occurs when the head turns beyond the normal range?

Excessive rotation

Which assessment findings indicate that a patient with a T4 spinal cord injury is developing autonomic dysreflexia? Select all that apply.

Flushing of the neck Profuse facial diaphoresis Heart rate 52 and irregular Blood pressure 150/90 mm Hg

A patient sustains a C8 spinal cord injury and is experiencing impaired motor function. During assessment, the nurse anticipates that the patient will be unable to perform what skill?

Grasping a ball or forming a fist

The nurse is caring for a patient with a spinal cord injury resulting from a diving accident who has a halo fixator and an indwelling urinary catheter in place. The nurse notes that the blood pressure is elevated and that the patient is reporting a severe headache. The nurse anticipates that the health care provider will request which medication?

Nifedipine

A patient admitted to the intensive care unit earlier that day after sustaining a cervical spinal cord injury in a motor vehicle crash is intubated and is receiving mechanical ventilation. The nurse notes a heart rate of 56 beats/min; blood pressure of 88/60 mm Hg; and warm, dry skin. Which action does the nurse perform next?

Notify the provider of these findings immediately

The nurse is monitoring a patient for major complications following lumbar spinal surgery. What assessments does the nurse make to monitor for fat embolism syndrome (FES)? Select all that apply.

Observe for chest pain, dyspnea, anxiety, and mental status changes. Note petechiae around the neck, upper chest, and conjunctiva

Following a spinal cord injury (SCI), what is the patient with weakness in the legs experiencing?

Paraparesis

What assessment finding is associated with a lower thoracic spinal cord injury?

Paraplegia

In the emergency department (ED), which is the nursing priority is assessing the patient with a spinal cord injury?

Patent airway

A patient is admitted with a spinal cord injury at the fifth thoracic vertebra secondary to a gunshot wound. Which nursing intervention is the priority for this patient's care?

Positioning the patient to maximize ventilation potential

The nurse performing an assessment on a patient 6 hours postoperative for diskectomy notices the presence of clear drainage from the incision site. The nurse suspects the drainage may be cerebrospinal fluid (CSF) and evaluates the patient for which accompanying sign/symptom?

Sudden headache

A patient is placed in a halo device to stabilize a cervical fracture. Which nursing action is a priority for this patient's safety?

Taping the wrench to the vest

Which statement about spinal cord injuries is correct?

They occur mostly in young males

In caring for a patient in the early postoperative period after anterior cervical diskectomy and fusion (ACDF), which nursing intervention is the priority?

Maintaining an open airway

What mechanism of spinal cord injury may result from diving accidents, falls on the buttocks, or a jump in which a person lands on the feet?

Vertical compression

In addition to frequent re-positioning, the nurse anticipates a consultation request for which special pressure relief device to help prevent pressure ulcers in the client with a spinal cord injury?

Chair pad

A patient is admitted to the intensive care unit with acute traumatic spinal injuries. Which parameters are part of the initial physical assessments that the nurse should perform? Select all that apply.

Level of consciousness Sensory and motor function Airway, breathing and circulation pattern

Which secondary spinal cord injury typically results from swelling of soft tissues due to increased interstitial fluid?

Local edema

A patient who has just undergone spinal surgery must be moved. How does the nurse plan to move this patient?

Log-rolling the patient

What term describes excessive inward curvature of the spine?

Lordosis

A patient has received preoperative teaching from the nurse for a microdiskectomy. Which statement by the patient indicates a correct understanding of the nurse's instruction?

'I can go home the day of the procedure.'

A patient is unable to move and has no tactile sensation following a diving accident. The provider is unable to elicit reflexes. The patient's family member asks if the patient will be paralyzed. How does the nurse respond to the family member?

'These findings may indicate a temporary response to the injury.'

A registered nurse is supervising the student nurse who is providing emergency care to a patient experiencing autonomic dysreflexia. Which action of the student nurse indicates the need for further teaching?

Administering beta blocker in the patient with recurrent dysreflexia

Which initial assessment is the first priority for a patient with a spinal cord injury?

Airway, breathing, and circulation

A patient returns to the neuromedicine floor after undergoing an anterior cervical diskectomy and fusion (ACDF). What is the nurse's first action?

Assess airway and breathing

The nurse is caring for a patient following spinal cord injury (SCI). The patient experiences a sudden rise in blood pressure, profuse sweating, and altered vision. What life-threatening condition does the nurse suspect?

Autonomic dysreflexia

A patient is admitted with the excessive rotation of the cervical vertebra. Which assessment findings should the nurse consider as contributing to secondary injuries in this patient? Select all that apply.

Blood pressure 78/56 mm Hg4 Respiratory rate 10 and shallow Pulse oximeter 88% on room air

The nurse observes that the patient is unable to grasp a pen and form a fist when assessing motor function. Based on this assessment, what is the most likely level of spinal cord injury in the patient?

C8

What are the priority collaborative problems for patients with acute spinal cord injuries (SCI)? Select all that apply.

Cardiovascular instability related to loss or interruption of sympathetic innervation or hemorrhage Decreased mobility and sensation related to spinal cord damage and edema Respiratory distress Secondary Spinal

The nurse is caring for a patient following a motor vehicle crash. What kind of spinal cord injury (SCI) indicates the patient is at high risk for respiratory compromise?

Cervical SCI

The nurse is performing a postoperative assessment on a patient after an open back diskectomy. The nurse becomes concerned that the wound drainage contains cerebrospinal fluid when it appears as what color?

Clear

The nurse is caring for a patient with a lumbosacral injury. The patient has blood pressure of 80/50 mm Hg. The nurse should give priority to the administration of which prescribed medication?

Dextran

The nurse is caring for a patient with severe chronic back pain. The primary health care provider orders an intrathecal infusion of ziconotide with a surgically implanted pump. Which action of the nurse is most appropriate in this situation?

Discontinuing the infusion if the patient exhibits delusions

A patient with severe muscle spasticity has been prescribed tizanidine. The nurse instructs the patient about which adverse effect of tizanidine?

Drowsiness

Which assessment findings alert the nurse that a patient with a spinal cord injury is experiencing autonomic dysreflexia? Select all that apply.

Headache Bradycardia Hypertension Nasal stuffiness

A nurse is planning a psychosocial assessment for a spinal cord injury (SCI) patient. How will the nurse assist the patient in identifying strategies to adjust to the disability? Select all that apply.

Help the patient set realistic goals and verbalize feelings. Assess if the home environment can accommodate the patient's special needs. Tell patient about the expected reactions of those outside the hospital environment. Collaborate with the case manager for a review of the patient's insurance and financial status

A patient with a T6 spinal cord injury who is in the rehabilitation unit suddenly develops facial flushing and reports a severe headache. Blood pressure is elevated, and the heart rate is slow. Which action does the nurse take first?

Help the patient sit up.

Which secondary spinal cord injury typically results from excessive bleeding?

Hemorrhage

Following a spinal cord injury (SCI), what is the patient reporting increased sensory sensation experiencing?

Hyperesthesia

Which mechanism of spinal cord injury occurs when the head is suddenly accelerated and then decelerated?

Hyperextension

A sudden and forceful acceleration of the head forward may cause which mechanism of spinal cord injury?

Hyperflexion

Which type of spinal cord injury causes tearing of posterior ligaments and dislocation of vertebrae in the patient?

Hyperflexion

Following a spinal cord injury (SCI), what is the patient reporting decreased sensory sensation experiencing?

Hypoesthesia

Which secondary spinal cord injury typically results from decreased circulating blood volume?

Hypovolemia

Which assessment finding indicates that patient may have damage to the sacral spinal nerves?

Inability to void

A patient with a spinal cord injury is on medication to control severe muscle spasticity. After a few days of receiving the medication, the patient experiences sedation, fatigue, dizziness, and changes in mental status. Which medication does the nurse anticipate has contributed to these symptoms?

Intrathecal baclofen

What secondary spinal cord injury typically results from reduced or absent blood flow?

Ishemia

Which statement about autonomic dysreflexia is accurate?

It can be caused by a distended bladder

A patient is being discharged with paraplegia secondary to a motor vehicle crash and expresses concern over the ability to cope in the home setting after the injury. Which is the best resource for the nurse to provide for the client?

National Spinal Cord Injury Association

Following a spinal cord injury (SCI), what is the patient with weakness in the legs and arms experiencing?

Quadraparesis

What is the nurse's priority action for a patient experiencing autonomic dysreflexia (AD)?

Raising the head of the bed

A patient who has undergone an anterior cervical diskectomy with fusion is experiencing difficulty swallowing a soft diet. The patient is breathing normally and is wearing a large neck brace. What is the nurse's best action?

Reassure the patient that this is usually a temporary postoperative effect

Which nursing intervention is best for preventing complications of immobility when caring for a client with spinal cord problems?

Regular turning and repositioning

Which condition is a patient at risk for following cervical spinal cord injury?

Respiratory compromise

A patient is admitted to the hospital following a motor vehicle accident. A spinal cord injury is suspected. The nurse identifies that which assessment finding should be addressed as a priority? Select all that apply.

Respiratory rate - 30 breaths per minute; shallow and rapid breaths BP - 90/60 mm of Hg, Pulse - 100 beats per minute; weak and thready pulse

To prevent the leading cause of death for patients with spinal cord injury, collaboration with which component of the health care team is a nursing priority?

Respiratory therapy

Which techniques are appropriate for patients with cervical neck pain? Select all that apply.

Seated rowing Shoulder shrug Shoulder squeeze

A patient with a history of breast cancer complains about episodes of sharp, piercing pain in the lower back which increases when coughing, straining, and lying flat. Which assessment findings would indicate the presence of spinal tumors in the lumbosacral region? Select all that apply.

Sexual dysfunction Bladder and bowel dysfunction Decreased ankle and knee reflexes

What is the complete but temporary loss of motor, sensory, reflex, and autonomic function following spinal cord injury?

Spinal shock

The nurse is monitoring a patient with acute spinal cord injury (SCI). Which findings indicate a respiratory emergency? Select all that apply.

Stridor Garbled speech Pulse oximetry less than 95% Systolic blood pressure (SBP) less than 90 mm Hg Mean arterial pressure (MAP) less than 65 mm Hg

The nurse is caring for a patient postoperatively after an anterior cervical diskectomy and fusion. Which assessment finding is of greatest concern to the nurse?

The patient is reporting difficulty swallowing secretions.

The nurse is caring for a patient in the emergency department whose spinal cord was injured at the level of C7 1 hour ago. Which assessment finding requires the most rapid action?

The patient's chest moves very little with each respiration.

More than a third of spinal cord injuries (SCIs) result from which cause?

Vehicle crashes