Case Study 7 Spinal Cord Injury

An hour later, Mr. M's oxygen saturation drops to 88% and his respirations are rapid and shallow. On auscultation, he has decreased breath sounds bilaterally. What is your best action at this time? 1. Increase o2 to 10 L/min 2. Suction the client's airway 3. Notify the HCP immediately 4. Call the respiratory therapist

3. Notify the HCP immediately

Mr. M has a nursing diagnosis of impaired physical mobility. Which nursing actions should you delegate to the nursing student on the unit? Select all that apply 1. Administering intravenous zantac 50 mg 2. monitoring traction ropes and weights 3. Assessing the client's neuro status for changes 4. Provide pin site care 5. Initiate the nursing care plan

1. Administering intravenous zantac 50 mg 4. Provide pin site care

Mr. M continues to be incontinent. You plan to establish a bladder retraining program for him. Which are important points for the program? 1. Remove the indwelling foley 2. Use intermittent catheterization q 4 3. Gradually increase intervals between catheterizations 4. Teach the patient to initiate voiding by tapping on his bladder q 4 5. Teach the patient how to perform self catheterization 6. Administer urecholine 20mg orally twice a day 7. Encourage the client to limit fluid intake to 1000 mL

1. Remove the indwelling foley 2. Use intermittent catheterization q 4 3. Gradually increase intervals between catheterizations 4. Teach the patient to initiate voiding by tapping on his bladder q 4 5. Teach the patient how to perform self catheterization 6. Administer urecholine 20mg orally twice a day

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 your 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

Which action to prevent complications from impaired physical mobility can you delegate to the UAP? 1. turning and repositioning q 2 2. Inspecting the client's skin for reddened areas 3. Performing ROM exercises every 8 hours 4. Administer enoxaparin

1. turning and repositioning q 2

Mr. M is a 32 y/o male brought to the ER by paramedics after a fall from the second story roof of his home. He was placed on a spinal board w/ a cervical collar to immobilize his spine. After spinal radiographs were obtained, the dr's determined that he has a vertebral compression injury at the c4-c5 level. What is your priority concern at this time? 1. Spinal immobilization 2. Airway 3. Potential for injuries r/t the client's decreased sensation 4. Dysrhythmias c/b disruption of the autonomic nervous system

2. Airway

Mr. M is stabilized and moved to the neurologic ICU w/ a diagnosis of SCI at level c4-c5. You are the admitting nurse, working with an experienced UAP. When frequent respiratory assessments are performed, which can you delegate to the UAP? (Select all that apply) 1. Auscultate breath sounds every hour to detect decreased or absent ventilation 2. Ensuring that oxygen is flowing at 5 L/ min via the NC 3. Teach the client to breathe slowly and deeply using the IS 4. Check the client's oxygen saturation by pulse oximetry every 2 hours. 5. Assessing the client's chest wall movement during respirations

2. Ensuring that oxygen is flowing at 5 L/ min via the NC 4. Check the client's oxygen saturation by pulse oximetry every 2 hours.

Mr. M is to be transferred to a rehab facility. Which statement indicates the client needs more teaching? 1. After rehab, i may be able to achieve control of my bladder. 2. With rehab, i will gain all of my motor functions 3. Rehab wil help me to become as independent as possible 4. After rehab, i hope to return to a gainful employment

2. With rehab, i will gain all of my motor functions

Mr. M's condition has stabilized and he has been removed from the ventilator. His cervical injury is now immobilized with a halo fixation device with jacket. He has regained the use of his arms and has some movement in his legs. Which instruction would you give the UAP providing help to Mr. M in ADLs? 1. Feed, bathe, and dress the client so he doesn't get too tired. 2. Encourage the patient to perform all of his own care 3. Allow the client to do what he can and then assist him with what he cant

3. Allow the client to do what he can and then assist him with what he cant

The nursing student asks you how best to assess Mr. M's motor function. What is your best response? 1. Apply resistance while the client lifts his legs from the bed 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 forms a fist

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