Adult 2 Ch. 61
The nurse is caring for a patient admitted with a spinal cord injury following a motor vehicle accident. The patient exhibits a complete loss of motor, sensory, and reflex activity below the injury level. The nurse recognizes this condition as which of the following? Central cord syndrome Spinal shock syndrome Anterior cord syndrome Brown-Séquard syndrome
About 50% of people with acute spinal cord injury experience a temporary loss of reflexes, sensation, and motor activity that is known as spinal shock. Central cord syndrome is manifested by motor and sensory loss greater in the upper extremities than the lower extremities. Anterior cord syndrome results in motor and sensory loss but not reflexes. Brown-Séquard syndrome is characterized by ipsilateral loss of motor function and contralateral loss of sensory function.
Which intervention should the nurse perform in the acute care of a patient with autonomic dysreflexia? Urinary catheterization Administration of benzodiazepines Suctioning of the patient's upper airway Placement of the patient in the Trendelenburg position
Because the most common cause of autonomic dysreflexia is bladder irritation, immediate catheterization to relieve bladder distention may be necessary. Benzodiazepines are contraindicated, and suctioning is likely unnecessary. The patient should be positioned upright.
While on a mission trip, the nurse is caring for a patient diagnosed with tetanus. The patient has been given tetanus immune globulin (TIG). What should be the focus of collaborative care (select all that apply)? Administration of penicillin Tracheostomy for mechanical ventilation Administration of polyvalent antitoxin Teach correct processing of canned foods. Control of spasms with diazepam (Valium)
Control of the spasms of tetanus is essential because the laryngeal and respiratory system spasms cause apnea and anoxia. A tracheostomy is performed early so mechanical ventilation may be done to maintain ventilation. Penicillin is administered for neurosyphilis. Use of polyvalent antitoxin and teaching the correct canning process is done for botulism.
The nurse is providing care for a patient who has been diagnosed with Guillain-Barré syndrome. Which assessment should be the nurse's priority? Pain assessment Glasgow Coma Scale Respiratory assessment Musculoskeletal assessment
Although all of the assessments are necessary in the care of patients with Guillain-Barré syndrome, the acute risk of respiratory failure necessitates vigilant monitoring of the patient's respiratory status.
The nurse performs discharge teaching for a 34-year-old male patient with a T2 spinal cord injury resulting from a construction accident. Which statement, if made by the patient to the nurse, indicates that teaching about recognition and management of autonomic dysreflexia is successful? "I will perform self-catheterization at least six times per day." "A reflex erection may cause an unsafe drop in blood pressure." "If I develop a severe headache, I will lie down for 15 to 20 minutes." "I can avoid this problem by taking medications to prevent leg spasms."
Autonomic dysreflexia is usually caused by a distended bladder. Performing self-catheterization five or six times a day prevents bladder distention. Signs and symptoms of autonomic dysreflexia include a severe headache. Patients should raise the head of the bed to 45 to 90 degrees. This action helps to relieve hypertension (systolic pressure up to 300 mm Hg) that occurs with autonomic dysreflexia.
Which clinical manifestation would the nurse interpret as a manifestation of neurogenic shock in a patient with acute spinal cord injury? Bradycardia Hypertension Neurogenic spasticity Bounding pedal pulses
Neurogenic shock is due to the loss of vasomotor tone caused by injury and is characterized by bradycardia and hypotension. Loss of sympathetic innervations causes peripheral vasodilation, venous pooling, and a decreased cardiac output. Thus hypertension, neurogenic spasticity, and bounding pedal pulses are not seen in neurogenic shock.
When planning care for a patient with a C5 spinal cord injury, which nursing diagnosis has the highest priority? Risk for impairment of tissue integrity caused by paralysis Altered patterns of urinary elimination caused by tetraplegia Altered family and individual coping caused by the extent of trauma Ineffective airway clearance caused by high cervical spinal cord injury
Maintaining a patent airway is the most important goal for a patient with a high cervical fracture. Although all of these are appropriate nursing diagnoses for a patient with a spinal cord injury, respiratory needs are always the highest priority. Remember the ABCs.
Which manifestations in a patient with a T4 spinal cord injury should alert the nurse to the possibility of autonomic dysreflexia? Headache and rising blood pressure Irregular respirations and shortness of breath Decreased level of consciousness or hallucinations Abdominal distention and absence of bowel sounds
Manifestations of autonomic dysreflexia are hypertension (up to 300 mm Hg systolic), a throbbing headache, bradycardia, and diaphoresis. Respiratory manifestations, decreased level of consciousness, and gastrointestinal manifestations are not characteristic manifestations.
A 19-year-old man is admitted to the emergency department with a C6 spinal cord injury after a motorcycle crash. Which medication should the nurse anticipate that she will administer first? Enoxaparin (Lovenox) Metoclopramide (Reglan) IV immunoglobulin (Sandoglobulin) Methylprednisolone sodium succinate (Solu-Medrol)
Methylprednisolone (MP) blocks lipid peroxidation by-products and improves blood flow and reduces edema in the spinal cord. High-dose MP should be administered within 8 hours of injury. Enoxaparin is a low-molecular-weight heparin used to prevent deep vein thrombosis. Metoclopramide is used to treat delayed gastric emptying. IV immunoglobulin (Sandoglobulin) is used to treat Guillain-Barré syndrome.
A 42-year-old man is admitted to the hospital with a diagnosis of Guillain-Barré syndrome. The physician orders include IV Sandoglobulin. What is important for the nurse to assess for before administration? Elevated fasting blood glucose and serum albumin Elevated activated partial thromboplastin time (aPTT) Elevated serum creatinine and blood urea nitrogen (BUN) Elevated aspartate aminotransferase and alanine aminotransferase
Patients receiving IV administration of high-dose immunoglobulin (Sandoglobulin) need to be well hydrated and have adequate renal function. Elevated serum creatinine and blood urea nitrogen indicate impaired renal function.
The nurse cares for a 63-year-old woman taking prednisone (Deltasone) and acyclovir (Zovirax) for Bell's palsy. It is most important for the nurse to follow up on which patient statement? "I can take both medications with food or milk." "I will take these medications for 2 to 3 months." "I can take acetaminophen with the prescribed medications." "Chances of a full recovery are good if I take the medications."
Prednisone and acyclovir will usually be prescribed for 10 days. Prednisone will be tapered over the last 4 days of treatment. Oral prednisone and acyclovir may be taken with food or milk to decrease gastrointestinal upset. Patients with Bell's palsy usually begin recovery in 2 to 3 weeks, and most patients have complete recovery in 2 to 3 months. Patients have the best chance for full recovery if prednisone is initiated before complete paralysis occurs. There are no serious drug interactions among prednisone, acyclovir, and acetaminophen.
After learning about rehabilitation for his spinal cord tumor, which statement shows the patient understands what rehabilitation is and can do for him? "I want to be rehabilitated for my daughter's wedding in 2 weeks." "Rehabilitation will be more work done by me alone to try to get better." "I will be able to do all my normal activities after I go through rehabilitation." "With rehabilitation, I will be able to function at my highest level of wellness."
Rehabilitation is an interdisciplinary endeavor carried out with a team approach to teach and enable the patient to function at the patient's highest level of wellness and adjustment. It will be a lot of work for all involved and take longer than 2 weeks. With neurologic dysfunction, the patient will not be able to do all the normal activities in the same way as before the lesion, so this statement should be discussed.
The patient with peripheral facial paresis on the left side of her face is diagnosed with Bell's palsy. What should the nurse include in teaching the patient about self-care (select all that apply)? Administration of antiseizure medications Preparing for a nerve block to relieve pain Administration of corticosteroid medications Dark glasses and artificial tears to protect the eyes Surgeries available if conservative therapy is not effective
Self-care for Bell's palsy includes corticosteroid medications to decrease inflammation of the facial nerve (CNVII) and protecting the cornea from drying out because of the inability to close the eyelid. Antiseizure medications, a nerve block, or surgeries are used for trigeminal neuralgia.
A 22-year-old female with paraplegia after a spinal cord injury tells the home care nurse that bowel incontinence occurs two or three times each day. Which action by the nurse is most appropriate? Take magnesium citrate (Citroma) every morning with breakfast. Teach the patient to gradually increase intake of high-fiber foods. Assess bowel movements for frequency, consistency, and volume. Instruct the patient to avoid all caffeinated and carbonated beverages.
The nurse should establish baseline bowel function and explore the patient's current knowledge of an appropriate bowel management program after spinal cord injury. To prevent constipation, caffeine intake should be limited, but not eliminated. Oral saline laxatives such as magnesium citrate are not indicated for long-term management of bowel elimination. Instruction on high-fiber foods is indicated if the patient has a knowledge deficit.
A 68-year-old patient with a spinal cord injury has a neurogenic bowel. Beyond the use of bisacodyl (Dulcolax) suppositories and digital stimulation, which measures should the nurse teach the patient and the caregiver to assist the patient with bowel evacuation (select all that apply)? Drink more milk. Eat 20-30 g of fiber per day. Use oral laxatives every day. Drink 1800 to 2800 mL of water or juice. Establish bowel evacuation time at bedtime.
The patient with a spinal cord injury and neurogenic bowel should eat 20-30 g of fiber and drink 1800 to 2800 mL of water or juice each day. Milk may cause constipation. Daily oral laxatives may cause diarrhea and are avoided unless necessary. Bowel evacuation time is usually established 30 minutes after the first meal of the day to take advantage of the gastrocolic reflex induced by eating.
A 25-year-old male patient who is a professional motocross racer has anterior spinal cord syndrome at T10. His history is significant for tobacco, alcohol, and marijuana use. What is the nurse's priority during rehabilitation? Prevent urinary tract infections. Monitor the patient every 15 minutes. Encourage him to verbalize his feelings. Teach him about using the gastrocolic reflex.
To help him with his coping and prevent self-harm, the nurse should create a therapeutic patient environment that encourages his self-expression and verbalization of thoughts and feelings. This patient is at high risk for depression and self-injury because he is likely to lose function below the umbilicus involving lost motor and sensory function. In addition, he is a young adult male patient who is likely to need a wheelchair, have impaired sexual function, and is unlikely to resume his racing career. Because the patient uses tobacco, alcohol, and marijuana frequently, hospitalization is likely to result in a loss of these habits that can make coping especially difficult for him. Prevention of urinary tract infections and facilitating bowel evacuation with the gastrocolic reflex will be important but not as important as helping him cope. In rehabilitation, monitoring every 15 minutes is not needed unless he is on a suicide watch.
