Module 10

List 4 manifestations of Autonomic Dysreflexia

Severe HA Hypertension Facial flushing Bradycardia

List 3 prescriptions for Autonomic Dysreflexia

Sit them up Find cause Loosen tight clothing Treat HTN

When preparing to receive a patient with a C2 injury, which priority action will the nurse take? A. Ensure that ventilation equipment is present. B. Prepare to obtain serial arterial blood gases. C. Plan an effective bowel program to prevent impaction. D. Request a prescription for physical and occupational therapy.

A Patients with Cl to C2 injuries experience paralysis of the diaphragm and are ventilator-dependent. The nurse will therefore ensure that all ventilation equipment is present. Other actions, such as preparing to obtain serial arterial blood gases, planning a bowel program, and requesting a prescription for physical and occupational therapy can take place after the nurse has ensured that airway management equipment is present.

Which assessment findings alert the nurse that the client who has a spinal cord injury is developing autonomic hyperreflexia (autonomic dysreflexia)? A. Hypertension and bradycardia B. Flaccid paralysis and numbness C. Absence of sweating and pyrexia D. Escalating tachycardia and shock

A. Hypertension and bradycardia occur as a result of exaggerated autonomic responses. If autonomic diaphoresis occurs above the level of injury. Bradycardia occurs rather than tachycardia. related to transection, not autonomic hyperreflexia; the client will have no sensation below the injury. Profuse hyperreflexia is identified, immediate intervention is necessary to prevent serious complications. Paralysis is

When assessing a client with diabetes insipidus, which signs would the nurse anticipate finding? Select all that apply. One, some, or all responses may be correct. A. Excessive thirst B. Increased blood glucose C. Dry mucous membranes D. Increased blood pressure E. Decreased serum osmolarity F. Decreased urine specific gravity

ACF As excessive fluid is lost through urination, dehydration triggers the thirst response. As excessive fluid is lost and poor skin turgor. Because through urination, dehydration occurs, resulting in dry mucous membranes water is not being reabsorbed, urine is dilute, resulting in a low specific gravity (less than 1.005). Diabetes insipidus is not a disorder of glucose metabolism; blood glucose affects glucose metabolism. Loss of fluid may decrease the blood pressure because fluid is lost from the levels are not affected. Diabetes mellitus intravascular compartment. As fluid is lost from the intravascular compartment, serum osmolarity increases, not decreases.

Which clinical findings would the nurse expect to see when assessing a client with a primary brain tumor who has developed syndrome of inappropriate secretion of antidiuretic hormone (SIADH)? Select all that apply. One, some, or all responses may be correct. A. Vomiting B. Hyperthermia C. Bradycardia D. Increased weight E. Decreased serum sodium F. Decreased level of consciousness

ADEF Water retention and decreased urinary output occur because of excess secretion of antidiuretic hormone. Early manifestations are related to water retention and may include gastrointestinal (GI) disturbances such as loss of appetite, nausea, and vomiting. Weight gain occurs because of the water retention. Serum retention and sodium loss. Central nervous system changes sodium levels are decreased because of fluid include headaches, lethargy, and decreased level of consciousness, Hypothermia also occurs because of central nervous system disturbance. The pulse is full and bounding progressing to coma and seizures. because of the increased fluid volume.

ED patient with a T4 injury, no reflexes below the injury, BP 76/54, & HR 52. The nurse should assess the client for? A. Autonomic dysreflexia B. Neurogenic shock C. Basilar skull fracture D. Increased intracranial pressure

B

Which symptom indicates central diabetes insipidus (DI) in a critically ill patient with a decreased level of consciousness? A. Pain B. Polyuria C. Bradycardia D. Reduced breath sounds

B In central DI, there is either absent or insufficient antidiuretic hormone (ADH), which causes the kidney to be unable to concentrate urine and retain water. If the patient is conscious, the thirst mechanism helps maintain the fluid balance. However, in the patient who has a decreased level of consciousness, polyuria is the symptom that indicates central DI. Pain in a critically ill patient with a decreased level of consciousness is not a symptom that indicates central DI. The patient who is dehydrated from DI will have tachycardia. Reduced breath sounds are not associated with central DI in a critically ill, unconscious patient.

Which rationale explains why the nurse would monitor a client who has a spinal cord injury at the T2 level for signs of autonomic hyperreflexia (autonomic dysreflexia)? A. The injury results in loss of the reflex arc. B. The injury is above the sixth thoracic vertebra. C. There has been a partial transection of the cord, D. There is a flaccid paralysis of the lower extremities.

B The T6 level is the sympathetic visceral outflow level. Because the client's injury is above this level (T2), autonomic hyperreflexia is expected. The reflex arc remains intact after spinal cord injury. The important point is not that the cord is transected, but the level at which the injury occurred. A flaccid paralysis of the lower extremities is not related to autonomic hyperreflexia. All cord injuries result in flaccid paralysis during the period of spinal shock; as the inflammation subsides, spasticity gradually increases.

Which assessments would the nurse include for a client with spine injuries who wears body jacket brace? Select all that apply. One, some, or all responses may be correct. A. Inspection of pin sites B. Development of cast syndrome C. Signs of compartment syndrome D. Auscultation for bowel sounds E. Skin over the thoracic bony prominences

BDE A client with a severe spine injury due to an accident would benefit from application of a body jacket brace, which immobilizes and supports the thoracic and lumbar spine. After application of the brace, the nurse would assess the cient for the development of cast syndrome. This condition occurs when a brace is tightly applied, compressing the superior mesenteric artery against the duodenum. A window in the brace may be left over the unbilicus. The nurse would monitor the reduction in bowel sounds to prevent abdominal pressure and pain, The nurse would assess the areas of pressure over the bony prominences such as the iliac crest and then adjust or remove the brace based upon any complications. A client with an external fixator will need pin sites assessed. A client with a lower extremity cast must regularly be assessed for signs of compartment syndrome and increased pressure at the heel, anterior tibia, head of the fibula, and malleoli.

A C5-C6 subluxation fracure patient moves his legs better than his arms. What intervention is expected? A. Keeping the room cool, dark, and quiet B. Elevating the head of the bed 45 degrees C. Administering IV methylprednisolone for the first 24 hrs after injury D. Resuscitating low blood pressure by only using IV fluid

C

A patient with a C3-C5 fracture is able to move his legs better than arms. Which is true of this spinal cord injury? A. He is likely to be in supraventricular tachycardia. B. Hyperthermia is common in patients with spinal cord injury. C. These patients do not usually require mechanical ventilation. D. It is expected for diaphragmatic involvement.

D

Which type of spinal cord injury occurs when a patient experiences a backward and downward motion of the head? A. Rotation B. Axial loading C. Hyperflexion D. Hyperextension

D Hyperextension injuries involve backward and downward motion of the head. With this injury, often seen in rear-end motor vehicle accidents, the spinal cord is stretched and distorted. Neurologic deficits associated with this injury are often caused by contusion and ischemia of the cord without significant bony involvement. "Whiplash' is a mild form of hyperextension injury. Rotation injury is sustained when severe rotation of the neck or body results in tearing of the posterior ligaments and displacement of the spinal column. An axial loading injury, also called a compression injury, is sustained from a vertical force along the spinal cord. Hyperflexion injury is sustained in the cervical area as a result of sudden deceleration motion, such as in a head-on motor vehicle accident.

Select all that apply. One, some, or all responses may be correct. Which clinical findings correspond with the secretion of antidiuretic hormone (ADH)? A. Edema B. Polyuria C. Bradycardia D. Muscle cramps E. Hyponatremia

DE Muscle cramps occur when sodium level is less than 125 mEg/L and are caused by osmotic fluid shift. ADH causes water retention, which dilutes serum electrolytes such as sodium, with a resultant hyponatremia. Edema is not usually seen in syndrome of inappropriate ADH (SIADH) because water retention is not extracellular, A decreased urine output occurs with SIADH because ADH causes reabsorption of fluid in the kidney glomeruli. The increased fluid volume associated with SlADH results in tachycardia, tachypnea, and crackles.

Name 4 prescriptions for Neurogenic Shock

Fluids Vasopressor Atropine Warming blankets

What are 3 manifestations of Neurogenic Shock?

Hypotension Bradycardia Warm/Dry Skin

Which type of spinal cord injury occurs when a patient's neck or body moves in such a way that results in tearing of the posterior ligaments and displacement of the spinal column? A. Rotation B. Axial loading C. Hyperflexion D. Hyperextension

A Rotation injury is sustained when severe rotation of the neck or body results in tearing of the posterior ligaments and displacement of the spinal column. An axial loading injury, also called a compression injury, is sustained from a vertical force along the spinal cord. Hyperflexion injury is sustained in the cervical area as a result of sudden deceleration motion, such as in a head-on motor vehicle accident. Hyperextension injuries involve backward and downward motion of the head. With this injury, often seen in rear-end motor vehicle accidents, the spinal cord is stretched and distorted.

Which nursing intervention has the highest priority for a client who was in a motor bike accident and has a severe neck injury? A. Assessing for crepitus B. Assessing for bleeding C. Maintaining a patent airway D. Performing neurological assessment

C nurse should assess, ensure, and maintain a patent airway first in a client with neck trauma. The nurse then may palpate the skin near the esophagus to assess crepitus, which indicates an injury to the esophagus. After ensuring airway patency, the nurse should assess for bleeding or impending shock. The nurse should also perform a neurological assessment for mental status, sensory level, and motor function, which holds a medium priority.

The nurse is caring for a client who is diagnosed with diabetes insipidus and is on intranasal desmopressin acetate (DDAVP). The client develops an upper respiratory tract infection during a hospital stay. Which alteration would the nurse anticipate in the client's prescription? A. Cessation of DDAVP administration B. Reduced DDAVP dose via oral route C. Reduced DDAVP dose via subcutaneous route D. Continuation of DDAVP administration via nasal route

C The client develops an upper respiratory tract infection while on DDAVP therapy for diabetes insipidus. The best alternative is to administer the DDAVP via oral or subcutaneous routes. The subcutaneous (parenteral) form of DDAVP is almost 10 times more potent than intranasal and oral forms. If opting for the subcutaneous route, the dose of DDAVP should be reduced. The DDAVP cannot be stopped because it can lead to uncontrolled fluid loss. The DDAVP can be continued in the prescribed dose if opting for the oral route, but it does not need to be reduced. The DDAVP cannot be administered via nasal route because the client has developed an upper respiratory tract infection.

The nurse arrives at the site of a one-car motor- vehicle accident and stops to render aid. The driver of the car is unconscious. After stabilizing the client's cervical spine, which action should the nurse take next? A. Carefully remove the driver from the car. B. Assess the client's pupils for reaction. C. Assess the client's airway. D. Attempt to wake the client up by shaking him.

C The nurse should stabilize the client's neck prior to removal from the car. The nurse must stabilize the client's neck before doing any further assessment. Most nurses don't carry penlights, and the cli- ent's pupil reaction can be determined after stabilization. The nurse must maintain a patent airway. Airway is the first step in resuscitation. Shaking the patient could cause further damage, possibly leading to paralysis.

The nurse is caring for a client who is admitted with a crushing injury to the spinal cord at the level of phrenic nerve origin. Which complication would the nurse anticipate when planning care? A. Prolonged coma B. Ventricular fibrillation C. Diaphragmatic paralysis D. Vagus nerve dysfunction

C The phrenic nerves innervate the diaphragm; therefore a crushing spinal cord injury above the level of phrenic origin will stop diaphragmatic contractions and result in respiratory paralysis. Cardiac activity is not affected; the heart is regulated by the autonomic nervous system from fibers originating in the medulla. Activities regulated by the vagus nerve are unaffected; the vagi originate in the medulla, which is superior to the cervical region. Cerebral function is not affected by injury to the lower neck, where the phrenic nerve originates.