Evolve 60

The nurse performs discharge teaching for a 34-yr-old male patient with a thoracic spinal cord injury (T2) from a construction accident. Which patient statement indicates teaching about 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."

"I will perform self-catheterization at least six times per day."

A 68-yr-old patient with a spinal cord injury has a neurogenic bowel. Beyond the use of bisacodyl suppositories and digital stimulation, which measures should the nurse teach the patient and caregiver to assist with bowel evacuation (select all that apply.)? -Drink more milk. -Eat 20-30 g of fiber per day. -Use oral laxatives every day. -Limit caffeinated beverages. -Drink 1800 to 2800 mL of water or juice. -Establish bowel evacuation time at bedtime

-Eat 20-30 g of fiber per day. -Limit caffeinated beverages. -Drink 1800 to 2800 mL of water or juice.

A 22-yr-old woman with paraplegia after a spinal cord injury tells the home care nurse she experiences bowel incontinence two or three times each day. Which action by the nurse is most appropriate? -insert a rectal stimulant suppository. - 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.

Assess bowel movements for frequency, consistency, and volume.

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

Bradycardia

When planning care for a patient with a cervical spinal cord injury (C5), which nursing diagnosis has the highest priority? -Impaired urinary elimination related to tetraplegia -Risk for impaired tissue integrity related to paralysis -Disabled family coping related to the extent of trauma -Ineffective airway clearance related to cervical spinal cord injury

Ineffective airway clearance related to cervical spinal cord injury

The nurse is caring for a patient admitted with a spinal cord injury after 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

Spinal shock syndrome

A patient learns about rehabilitation for a spinal cord tumor. Which statement by the patient reflects appropriate understanding of this process? -"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."

With rehabilitation, I will be able to function at my highest level of wellness."

The nurse is caring for a 63-yr-old woman taking prednisone (Deltasone) for Bell's palsy. Which statement by the patient requires correction by the nurse? -"I can take the medication with food or milk." -"The medication should be started 1 week after paralysis." -"I can take acetaminophen with the prescribed medications." -"Chances of a full recovery are good if I take the medication"

"The medication should be started 1 week after paralysis."

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 interprofessional care is appropriate (select all that apply.)? -Administer penicillin. -Administer polyvalent antitoxin. -Control spasms with diazepam (Valium). -Teach correct processing of canned foods. -Provide analgesia with opioids (morphine). -Prepare for tracheostomy for mechanical ventilation.

-Administer penicillin. -Control spasms with diazepam (Valium). -Provide analgesia with opioids (morphine). -Prepare for tracheostomy for mechanical ventilation.

The patient with peripheral facial paresis on the left side is diagnosed with Bell's palsy. What should the nurse teach regarding self-care (select all that apply.)? -Administration of corticosteroid medications -Dark glasses and artificial tears to protect the eyes -A facial sling to support the muscles and facilitate eating -Surgery if conservative therapy is not effective -Preparing for a nerve block to manage pain -Administration of antiseizure medications

-Administration of corticosteroid medications -Dark glasses and artificial tears to protect the eyes -A facial sling to support the muscles and facilitate eating

Which manifestations in a patient with a thoracic spinal cord injury (T4) should alert the nurse to possible 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

Headache and rising blood pressure

Which intervention should the nurse perform first in the acute care of a patient with autonomic dysreflexia? -Urinary catheterization -Check for bowel impaction -elevate the head of the bed - Administer intravenous hydralazine

Elevate the head of the bed

A 25-yr-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 when planning for rehabilitation? -Prevent urinary tract infection. -Monitor the patient every 15 minutes. -Teach him about using the gastrocolic reflex. -Encourage him to verbalize his feelings.

Encourage him to verbalize his feelings.

The nurse is caring for a patient with a halo vest after cervical spine injury. Which care instructions should the nurse include in the patient's discharge plan? -Keep a wrench close or attached to the vest. -Use the frame and vest to assist in positioning. -Clean around the pins using betadine swab sticks. -Loosen both sides of the vest to provide skin care.

Keep a wrench close or attached to the vest.

The nurse is providing care for a patient diagnosed with Guillain-Barré syndrome. Which assessment should be the nurse's priority? -Pain assessment -Glasgow Coma Scale -Respiratory assessment -Musculoskeletal assessment

Respiratory assessment