NUR 1700 Q6 Randoms

The nurse has given medication instructions to the client receiving phenytoin (Dilantin). The nurse determines that the client understands the instructions if the client makes which comment?

"Good oral hygiene is needed, including brushing and flossing."

A nurse is teaching the family of a client who has a new diagnosis of epilepsy about actions to take if the client experiences a seizure. Which of the following instructions should the nurse include in the teaching? "Insert a padded tongue blade into the client's mouth." "Restrain the client." "Place the client on his back." "Move objects away from the client."

"Move objects away from the client." The nurse should instruct the family to move objects away from the client to reduce the risk of injury to the client.

The nurse is monitoring a client with a spinal cord injury who is experiencing spinal shock. Which assessment will provide the nurse with the best information about recovery from the spinal shock? 1.Reflexes 2.Pulse rate 3.Temperature 4.Blood pressure

1.Reflexes Areflexia characterizes spinal shock; therefore, reflexes should provide the best information. Vital sign changes are not consistently affected by spinal shock.

The nurse is caring for a client who sustained a spinal cord injury. While administering morning care, the client developed signs and symptoms of autonomic dysreflexia. Which is the initial nursing action? 1.Elevate the head of the bed. 2.Digitally examine the rectum. 3.Check the client's blood pressure. 4.Place the client in the prone position

1. Elevate the head of the bed. Autonomic dysreflexia is a serious complication that can occur in the spinal cord of the injured client. Once the syndrome is identified, the nurse elevates the head of the client's bed and then examines the client for the source of noxious stimuli. The nurse also assesses the client's blood pressure, but the initial action is to elevate the head of the bed.

Phenytoin 100 mg orally three times daily, has been prescribed for a client for seizure control. The nurse reinforces instructions regarding the medication to the client. which statement by the client indicates an understanding of the instructions? 1. I will use a soft toothbrush to brush my teeth 2. its alright to break the capsules to make it easier for me to swallow them 3. if I forget to take my medication, I can wait until the next dose and eliminate that dose 4. if my throat becomes sore, its a normal effect of the medication and its nothing to be concerned about

1. I will use a soft toothbrush to brush my teeth

A nurse in the emergency department is caring for a client who has a compression fracture of a spinal vertebra. During transport to the facility, the client was medicated with intravenous morphine. On arrival, the neurosurgeon determined urgent surgical intervention is indicated for the fracture. Staff members have been unable to reach the client's family. Which of the following actions should the nurse anticipate the neurosurgeon taking? 1. Invoking implied consent 2. Delaying the surgery until a member of the clients family is reached 3. Asking the client to sign the surgical consent form 4. Prescribing naloxone to reverse the effects of the morphine

1. Invoking implied consent The client is unable to sign the consent form because he is sedated from the morphine. The neurosurgeon has the legal right to invoke implied consent and proceed with the surgery if it is determined an emergency and surgery is in the clients best interest. The neurosurgeon should document the specifics of the situation in the clients medical record.

The nurse has provided discharge instructions to a client with an application of a halo device. The nurse determines that the client needs FURTHER teaching if which statement is made? 1. i will use a straw for drinking 2. i will drive only during the daytime 3. i will use caution because the device alters balance 4. i will wash the skin daily under the lamb's wool liner of the vest

2. i will drive only during the daytime

The nurse is caring for the client who has suffered spinal cord injury. The nurse further monitors the client for signs of autonomic dysreflexia and suspects this complication if which sign/symptom is noted? 1. sudden tachycardia 2. pallor of the face and neck 3. severe, throbbing headache 4. severe and sudden hypotension

3. severe, throbbing headache

The client with a cervical spine injury has Crutchfield tongs applied in the emergency department. The nurse should perform which essential action when caring for this client? 1. providing a standard bed frame 2. removing the weights to reposition the client 3. removing the weights if the client is uncomfortable 4. comparing the amount of prescribed weights with the amount in use

4. comparing the amount of prescribed weights with the amount in use

A nurse is planning care for a client who has quadriplegia. Which of the following actions should the nurse take to prevent a pulmonary embolism? A. Assess legs for redness B. Apply elastic compression stockings C. Perform passive range of motion exercises D. Monitor INR results E. Massage calves every shift

A. Assess legs for redness B. Apply elastic compression stockings C. Perform passive range of motion exercises D. Monitor INR results

A nurse is caring for a child who is having a seizure. Which of the following actions should the nurse take? (Select all that apply.) A. Assess the client's airway patency. B. Place a tongue depressor in the client's mouth. C. Remove objects from the clients bed. D. Place the client in a side-lying position. E. Restrain the client.

A. Assess the client's airway patency. C. Remove objects from the clients bed. D. Place the client in a side-lying position.

A nurse is teaching the family of a client who is receiving treatment for a spinal cord injury with a halo fixation device. Which of the following statements should the nurse make? a. Turn the screws on the device once a day b. Assess for signs of infection c. Apply talcum powder under the vest to limit friction d. The purpose of the device is to allow for neck movement during the healing process

Assess for signs of infection

A patient with a spinal cord injury (SCI) complains about a severe throbbing headache that suddenly started a short time ago. Assessment of the patient reveals increased blood pressure (168/94) and decreased heart rate (48/minute), diaphoresis, and flushing of the face and neck. What action should you take first? A Administer the ordered acetaminophen (Tylenol). B Check the Foley tubing for kinks or obstruction. C Adjust the temperature in the patient's room. D Notify the physician about the change in status.

B Check the Foley tubing for kinks or obstruction. Rationale: B. These signs and symptoms are characteristic of autonomic dysreflexia, a neurologic emergency that must be promptly treated to prevent a hypertensive stroke. The cause of this syndrome is noxious stimuli, most often a distended bladder or constipation, so checking for poor catheter drainage, bladder distention, or fecal impaction is the first action that should be taken. Option C: Adjusting the room temperature may be helpful, since too cool a temperature in the room may contribute to the problem. Option A: Tylenol will not decrease the autonomic dysreflexia that is causing the patient's headache. Option D: Notification of the physician may be necessary if nursing actions do not resolve symptoms. Focus: Prioritization

A nurse is caring for a client who has paraplegia following an automobile accident. The client is on an intermittent urinary catheterization program. Which of the following findings indicates the need for catheterization? A. Urge incontinence B. Dribbling of urine C. Weight gain D. Rectal distention

B. Dribbling of urine

A nurse is caring for a client with a spinal cord injury who reports a severe headache and is sweating profusely. Vital signs include BP of 220/110 mm Hg, with an apical heart rate of 54/min. Which of the following actions should the nurse take first? A. Notify the provider. B. Sit the client upright in bed. C. Check the client's urinary catheter for blockage. D. Administer antihypertensive medication.

B. Sit the client upright in bed. The greatest risk to the client is experiencing a cerebrovascular accident (stroke)secondary to elevated blood pressure. The first action by the nurse is to elevate the head of the bed until the client is in an upright position. This will lower the blood pressure secondary to postural hypotension.

The nurse is monitoring a client with a C5 spinal cord injury for spinal shock. Which findings would be associated with spinal shock in this client? Select all that apply.

Bowel sounds are absent. The client's abdomen is distended. Respiratory excursion is diminished. Accessory muscles of respiration are areflexic.

The student nurse is assisting the nurse in turning a patient who is in cervical traction. What is most important for the LPN/LVN to instruct the student to do when assisting in turning the patient? A. Flex the knees and hips before turning the patient. B. Support the patient's head with a pillow so that his neck is flexed. C. Turn the patient slowly and as one unit to avoid twisting the spine. D. Place the patient's back in traction so that the spine will be kept slightly flexed.

C. Turn the patient slowly and as one unit to avoid twisting the spine One of the most important interventions when turning a patient in traction, or turning any patient with a spinal cord injury, is to logroll the patient in order to avoid twisting the vertebral column and further damaging the spinal cord. Nurses should always assist in turning a patient with a spinal cord injury; this intervention should never be delegated to assistive personnel.

The nurse is caring for a patient admitted 1 week ago with an acute spinal cord injury. Which of the following assessment findings would alert the nurse to the presence of autonomic dysreflexia? A) Tachycardia B) Hypotension C) Hot, dry skin D) Throbbing headache

Correct Answer(s): D Autonomic dysreflexia is related to reflex stimulation of the sympathetic nervous system reflected by hypertension, bradycardia, throbbing headache, and diaphoresis.

A nurse is caring for a client who experienced a cervical spine injury 24 hr ago. Which of the following types of prescribed medications should the nurse clarify with the provider? A. Glucocorticoids B. Plasma expanders C. H 2 antagonists D. Muscle relaxants

D. Muscle relaxants The client will still be in spinal shock 24 hr following the injury. The client will not experience muscle spasms until after the spinal shock has resolved, making muscle relaxants unnecessary at this time.

A nurse is planning care for a female client who has a T4 spinal cord injury and is at risk for acquiring urinary tract infections. Which of the following actions should the nurse include in the client's plan of care? Cleanse the perineum from back to front. Obtain a prescription for an indwelling urinary catheter. Encourage fluid intake at and between meals. Offer the client the bedpan every 2 hr.

Encourage fluid intake at and between meals. Increased fluid intake dilutes the urine, reduces stasis, and greatly reduces the urinary bacterial count. Consequently, the risk of nosocomial (hospital-acquired) UTI is reduced, even for a client who has a spinal cord injury.

A nurse is assessing a client who is in skeletal traction. Which of the following should the nurse identify as an indication of infection at the pin sites? a. Serosanguineous drainage b. Mild erythema c. Warmth d. Fever

Fever

A nurse is reinforcing teaching elimination with an adolescent who is paralyzed from the waist down following a spinal cord injury. Which of the following statements by the adolescent indicates a need for further teaching? - I need to catheterize myself twice a day - I carry a water bottle with me because I drink a lot of water - I use a suppository every night to have a BM -I do my wheelchair exercises sitting in my chair.

I need to catheterize myself twice a day

A nurse is performing discharge teaching for a client who has seizures and a new prescription for phenytoin. Which of the following statements by the client indicates a need for further teaching? A. "I will notify my doctor before taking any other medications." B. "I have made an appointment to see my dentist next week." C."I know that I cannot switch brands of this medication." D. "I'll be glad when I can stop taking this medicine."

I'll be glad when I can stop taking this medicine.

A nurse is preparing to turn a client who is obese following a spinal fusion. The nurse should plan to use which of the following techniques to turn this client?

Log roll. (Spinal fusion is the insertion of bone graft from the iliac crest between vertebrae of the spinal column, which fuses the vertebrae to ensure stability. A client following this type of surgical procedure must be repositioned using a log roll technique. This technique maintains proper alignment by moving all body parts at the same time, preventing tension or twisting of the spinal column.)

A nurse is caring for a client following a lumbar laminectomy. Which of the following actions should the nurse take? - Have the client wear a cervical collar for the first 12 hr. -Log roll the client every 2 hr -Supine with her arms elevated on pillows -Head of her bed elevated 30 degrees.

Logroll the client every 2 hr

A nurse enters a client's room and finds him on the floor in the clonic phase of a tonic-clonic seizure. Which of the following actions should the nurse take? Insert a padded tongue blade into the client's mouth. Place a pillow under the client's head. Gently restrain the client's extremities. Apply a face mask for oxygen administration.

Place a pillow under the client's head. The nurse should place a small pillow or other soft padding under the client's head to protect the client from injury during the seizure, and turn his head to the side to keep the airway clear.

A nurse enters a client's room and finds the client on the floor having a seizure. Which of the following actions should the nurse take? Insert a tongue blade in the client's mouth. Place the client on his side. Hold the client's arms and legs from moving. Place the client back in bed.

Place the client on his side. The nurse should place the client on his side. This position drops the tongue to the side of the client's mouth and prevents the client's airway from being obstructed.

A nurse is contributing to the plan of care for a client who has spinal cord injury at level C8 who is admitted for comprehensive rehabilitation. Which of the following long-term goals is appropriate with regard to the client's mobility? - Walk with leg braces and crutches - Drive an electric wheelchair with a hand control device. - Drive an electric wheelchair equipped with a chin-control device - Propel a wheelchair equipped with knobs on the wheels

Propel a w/c equipped with knobs on the wheels

A nurse is contributing to the plan of care for a client who has a spinal cord injury resulting in paraplegia. Which of the following interventions should the nurse include? -Provide a high-protein, High-calorie diet. - Perform passive range of motion exercises daily. - Use sequential compression devices for 4 hour three times a day. - Develop a schedule to restrict fluid intake.

Provide a high-protein, high- calorie diet.

A nurse is in a client's room when the client begins having a tonic-clonic seizure. Which of the following actions should the nurse take first? Turn the client's head to the side. Check the client's motor strength. Loosen the clothing around the client's waist. Document the time the seizure began.

Turn the client's head to the side. The first action the nurse should take when using the airway, breathing, circulation approach to client care is to turn the client's head to the side. This action keeps the client's airway clear of secretion to prevent aspiration.

A client is 1 day post-op following spinal fusion. What should the nurse do? a) Log roll the client every 2 hr. b) Assist the client to sit upright in a chair for 4 hr at a time. c) Expect clear drainage on the spinal dressing. d) Elevate the client's legs when he is sitting in a chair.

a) Log roll the client every 2 hr.

A nurse is planning care for a client who has a halo fixation device. Which of the following actions should the nurse include in the plan of care? a) Monitor the client for an elevated temperature. b) Provide range of motion to the client's neck. c) Remove the vest daily to inspect the client's skin integrity. d) Check that the halo jacket is snug against the client's skin.

a) Monitor the client for an elevated temperature.

A nurse i caring for a client who is post-op in skeletal traction. When assisting the client, the nurse should expect what findings? (Select all that apply.) a) Slight pain at the insertion site b) Serous drainage on the dressing c) Movement of the pin at the insertion site d) Elastic bandages secure around the traction ropes e) Minimal edema around the pin

a) Slight pain at the insertion site b) Serous drainage on the dressing e) Minimal edema around the pin

A nurse is assessing a client in skeletal traction. The nurse correct which finding? a) The ropes are in the center of the wheel grooves. b) The weights rest against the foot of the bed. c) The weights are equal on each side. d) The ropes are securely attached to the pins.

b) The weights rest against the foot of the bed.

A patient with a history of a T2 spinal cord tells the nurse, "I feel awful today. My head is throbbing, and I feel sick to my stomach." Which action should the nurse take first? a. Notify the patient's health care provider. b. Check the blood pressure (BP). c. Give the ordered antiemetic. d. Assess for a fecal impaction.

b. Check the blood pressure (BP). Rationale: The BP should be assessed immediately in a patient with an injury at the T6 level or higher who complains of a headache to determine whether autonomic dysreflexia is causing the symptoms, including hypertension. Notification of the patient's health care provider is appropriate after the BP is obtained. Administration of an antiemetic is indicated after autonomic dysreflexia is ruled out as the cause of the nausea. The nurse may assess for a fecal impaction, but this should be done after checking the BP and lidocaine jelly should be used to prevent further increases in the BP.

A patient with a T1 spinal cord injury is admitted to the intensive care unit (ICU). The nurse will teach the patient and family that a. use of the shoulders will be preserved. b. full function of the patient's arms will be retained. c. total loss of respiratory function may occur temporarily. d. elevations in heart rate are common with this type of injury.

b. full function of the patient's arms will be retained. Rationale: The patient with a T1 injury can expect to retain full motor and sensory function of the arms. Use of only the shoulders is associated with cervical spine injury. Total loss of respiratory function occurs with injuries above the C4 level and is permanent. Bradycardia is associated with injuries above the T6 level.

When caring for a patient who was admitted 24 hours previously with a C5 spinal cord injury, which nursing action has the highest priority? a. Continuous cardiac monitoring for bradycardia b. Administration of methylprednisolone (Solu-Medrol) infusion c. Assessment of respiratory rate and depth d. Application of pneumatic compression devices to both legs

c. Assessment of respiratory rate and depth Rationale: Edema around the area of injury may lead to damage above the C4 level, so the highest priority is assessment of the patient's respiratory function. The other actions are also appropriate but are not as important as assessment of respiratory effort.

A client with a seizure disorder is being admitted to the hospital. Which should the nurse plan to implement for this client? Select all that apply. 1. Pad the bed's side rails. 2. Place an airway at the bedside. 3. Place oxygen equipment at the bedside. 4. Place suction equipment at the bedside. 5. Tape a padded tongue blade to the wall at the head of the bed.

1. Pad the bed's side rails. 2. Place an airway at the bedside. 3. Place oxygen equipment at the bedside. 4. Place suction equipment at the bedside. Rationale:The nurse should plan seizure precautions for a client with a seizure disorder. The precautions include padded side rails and an airway (to maintain airway patency if required), and oxygen and suction equipment at the bedside. Attempts to force a padded tongue blade between clenched teeth may result in injury to the teeth and mouth; therefore, a padded tongue blade is not placed at the bedside.

Which symptoms would validate the diagnosis of a cluster headache? Select all that apply. 1.A runny nose 2.Photophobia 3.Phonophobia 4.Burning sensation in the eye 5.Tearing on the affected eye

1.A runny nose 4.Burning sensation in the eye 5.Tearing on the affected eye

The nurse is monitoring a client with a C5 spinal cord injury for spinal shock. Which findings would be associated with spinal shock in this client? Select all that apply. 1.Bowel sounds are absent. 2.The client's abdomen is distended. 3.Respiratory excursion is diminished. 4.The blood pressure rises when the client sits up. 5.Accessory muscles of respiration are areflexic.

1.Bowel sounds are absent. 2.The client's abdomen is distended. 3.Respiratory excursion is diminished. 5.Accessory muscles of respiration are areflexic.

The nurse is planning care for a client in spinal shock. Which action would be least helpful in minimizing the effects of vasodilation below the level of the injury? 1.Moving the client quickly as one unit 2.Using vasopressor medications, as prescribed 3.Applying compression stockings, as prescribed 4.Monitoring vital signs before and during position changes

1.Moving the client quickly as one unit Reflex vasodilation below the level of spinal cord injury places the client at risk of orthostatic hypotension, which may be profound. Actions to minimize this include measuring vital signs before and during position changes, use of a tilt table in early mobilization, and changing the client's position slowly. Venous pooling can be reduced by using compression stockings, if prescribed. Vasopressor medications are used as per protocol and as prescribed.

The nurse is caring for a client who begins to experience seizure activity while in bed. Which actions by the nurse would be contraindicated? Select all that apply. 1.Restrain the client's limbs. 2.Loosen restrictive clothing. 3.Consider insertion of a padded tongue blade. 4.Remove the pillow and raise the padded side rails. 5.Position the client to the side, if possible, with head flexed forward.

1.Restrain the client's limbs.

A nurse in the emergency department is monitoring a client who has a cervical spinal cord injury from a fall. The nurse should monitor the client for which of the following complications? A. Hypotension B. Polyuria C. Hyperthermia D. Absence of bowel sounds E. Weakened gag reflex

A. Hypotension D. Absence of bowel sounds E. Weakened gag reflex

A client has a halo vest that was applied following a C6 spinal cord injury. The nurse performs which action to determine whether the client is ready to begin sitting up? 1.Puts both of the client's hip joints through full range of motion 2.Compares the client's pulse and blood pressure when both flat and sitting 3.Loosens the vest to gather data on the client's ability to support his own trunk 4.Inspects the halo vest pin sites to monitor for purulent drainage, redness, and pain

2.Compares the client's pulse and blood pressure when both flat and sitting Clients with cervical spinal cord injuries may lose control over peripheral vasoconstriction, causing postural (orthostatic) hypotension when upright. A drop of 15 mm Hg in the systolic pressure or 10 mm Hg in the diastolic pressure accompanied by an increase in heart rate when the head is elevated may indicate autonomic insufficiency that can cause dizziness or syncope in the upright position.

Which signs/symptoms are observed in the clonic phase of a seizure? Select all that apply. 1.Body stiffening 2.Muscular relaxation 3.Sudden loss of consciousness 4.Brief flexion of the extremities 5.Extension spasms of the body 6.Contortion of the face with eye rolling

2.Muscular relaxation 5.Extension spasms of the body 6.Contortion of the face with eye rolling

A client with spinal cord injury has experienced more than one episode of autonomic dysreflexia. The nurse should avoid which action that could trigger an episode of this complication? 1.Preventing pressure on the client's lower limbs 2.Rigidly adhering to a bowel retraining program 3.Allowing the client's bladder to become distended 4.Keeping the linen under the client free of wrinkles

3.Allowing the client's bladder to become distended

A client is admitted to the emergency department with a C4 spinal cord injury. The nurse performs which intervention first when collecting data on the client? 1.Taking the temperature 2.Observing for dyskinesia 3.Monitoring the respiratory rate 4.Checking extremity muscle strength

3.Monitoring the respiratory rate

A client is admitted to the emergency department with a C4 spinal cord injury. The nurse performs which intervention first when collecting data on the client? 1.Taking the temperature 2.Observing for dyskinesia 3.Monitoring the respiratory rate 4.Checking extremity muscle strength

3.Monitoring the respiratory rate. Because respiratory compromise is a leading cause of death in cervical spinal cord injury, respiratory assessment is the highest priority.

A halo vest is applied to a client following a cervical spine fracture. The nurse reinforces instructions to the client regarding safety measures related to the vest. Which statement by the client indicates a need for further teaching? 1."I will scan the room to see things." 2."I will wear rubber-soled shoes for walking." 3."I will use a walker for ambulating if I need to." 4."I will bend at the waist, keeping the halo vest straight to pick up items."

4. "I will bend at the waist, keeping the halo vest straight to pick up items." The client with a halo vest should avoid bending at the waist because the halo vest is heavy and the client's trunk is limited in flexibility. It is helpful for the client to scan the environment visually because the client's peripheral vision is diminished from keeping the neck in a stationary position. Use of a walker and rubber-soled shoes may help prevent falls and injury, so these items are also helpful.

The client with spinal cord injury is prone to experiencing autonomic dysreflexia. The least appropriate measure to minimize the risk of autonomic dysreflexia is which action? 1. strictly adhering to a bowl retraining program 2. keeping the linen wrinkle free under the client 3. avoiding unnecessary pressure on the lower limbs 4. limiting bladder cathererization to once every 12 hours

4. limiting bladder cathererization to once every 12 hours

The client is admitted to the hospital for observation with a probable minor head injury after an automobile crash. The nurse expects the cervical collar will remain in place until which time? 1. the client is taken for spinal x-rays 2. the family comes to visit after surgery 3. the nurse needs to provide physical care 4. the primary health care provider reviews the x-ray results

4. the primary health care provider reviews the x-ray results

The nurse is monitoring a client with a spinal cord injury for signs of spinal shock. Which sign is indicative of this complication of a spinal cord injury? 1.Hypertension 2.Tachycardia 3.Profuse diaphoresis 4.Areflexia below the level of injury

4.Areflexia below the level of injury Spinal shock represents a temporary but profound disruption of spinal cord function, which occurs immediately after injury and is clinically evident within 30 to 60 minutes. It is a state of areflexia characterized by the loss of all neurological function below the level of injury. Flaccid paralysis, bradycardia, and hypotension occur. The body is unable to use either shivering or perspiring as a means of controlling body temperature.

A client who is paraplegic after spinal cord injury has been taught muscle-strengthening exercises for the upper body. The nurse determines that the client will derive the least muscle-strengthening benefit from which activity? 1.Squeezing rubber balls 2.Doing push-ups in a prone position 3.Extending the arms while holding weights 4.Doing active range of motion to finger joints

4.Doing active range of motion to finger joints

A client with a T4 spinal cord injury is to be monitored for autonomic dysreflexia (hyperreflexia). Which finding is indicative of this complication? 1.Pupil responses are brisk bilaterally. 2.Knee-jerk reaction is absent bilaterally. 3.One hundred mL of residual urine remains after the client voids. 4.The client complains of a headache, and the blood pressure is elevated.

4.The client complains of a headache, and the blood pressure is elevated..

Which of the following signs and symptoms in a patient with a T4 spinal cord injury should alert the nurse to the possibility of autonomic dysreflexia? A) Headache and rising blood pressure B) Irregular respirations and shortness of breath C) Decreased level of consciousness or hallucinations D) Abdominal distention and absence of bowel sounds

A) Headache and rising blood pressure Among the manifestations of autonomic dysreflexia are hypertension (up to 300 mm Hg systolic) and a throbbing headache. Respiratory manifestations, decreased level of consciousness, and gastrointestinal manifestations are not characteristic

Which of the following interventions should the nurse perform in the acute care of a patient with autonomic dysreflexia? A) Urinary catheterization B) Administration of benzodiazepines C) Suctioning of the patient's upper airway D) Placement of the patient in the Trendelenburg position

A) Urinary catheterization Because the most common cause of autonomic dysreflexia is bladder irritation, immediate catheterization to relieve bladder distention may be necessary. The patient should be positioned upright. Benzodiazepines are contraindicated and suctioning is likely unnecessary.

A nurse is caring for a client who ingested a poison and is now experiencing a seizure. Which of the following is the priority action the nurse should take? A. Check the patency of the client's airway. B. Determine the poison that was ingested. C. Identify the amount of poison that was ingested. D. Position the client side-lying.

A. Check the patency of the client's airway.

A nurse is caring for a client who experienced a cervical spine injury 3 months ago. Which of the following types of bladder management methods should the nurse use for this client? A. Condom catheter B. Intermittent urinary catheterization C. Credé's method D. Indwelling urinary catheter

A. Condom catheter A client who has a cervical spinal cord injury will also have an upper motor neuron injury, which is manifested by a spastic bladder. Because the bladder will empty on its own, a condom catheter is an appropriate method and is noninvasive.

A nurse is planning care for a client who suffered a spinal cord injury (SCI) involving a T12 fracture1 week ago. The client has no muscle control of the lower limbs, bowel, or bladder. Which of the following should be the nurse's highest priority? A. Prevention of further damage to the spinal cord B. Prevention of contractures of the lower extremities C. Prevention of skin breakdown of areas that lack sensation D. Prevention of postural hypotension when placing the client in a wheelchair

A. Prevention of further damage to the spinal cord The greatest risk to the client during the acute phase of a SCI is further damage to the spinal cord. Therefore, when planning care, the priority should be the prevention of further damage to the spinal cord by administration of corticosteroids, minimizing movement of the client until spinal stabilization is accomplished through either traction or surgery, and adequate oxygenation of the client to decrease ischemia of the spinal cord.

A nurse is in a clients room when the client begins having a tonic- clonic seizure. Which of the following actions should the nurse take first? A. Turn the client's head to the side. B. Check the client's motor strength. C. Loosing the clothing around the client's waste. D. Document the time the seizure began.

A. Turn the client's head to the side.

A nurse is caring for a client who is experiencing a seizure. Which of the following actions should the nurse take? (Select all that apply.) Loosen restrictive clothing. Insert a bite stick into the client's mouth. Place the client into a supine position. Place a pillow under the client's head. Apply restraints.

Loosen restrictive clothing. Place a pillow under the client's head is correct.

A nurse is caring for a client who has a T-4 spinal cord injury. Which of the following client findings should the nurse identify as an indication the client is at risk for experiencing autonomic dysreflexia? The client states having a severe headache. The client's bladder becomes distended. The client's blood pressure becomes elevated. The client states having nasal congestion.

The client's bladder becomes distended. Autonomic dysreflexia (sometimes called hyperreflexia) can occur in clients with a spinal cord injury at or above the T6 level. Autonomic dysreflexia happens when there is an irritation, pain, or stimulus to the nervous system below the level of injury. There are many kinds of stimulation that can precipitate autonomic dysreflexia. For example, catheter changes, a distended bladder or bowel, enemas, and sudden position changes. Manifestations include elevated blood pressure, severe headache, and flushed face.

A nurse is developing a plan of care to prevent skin breakdown for a client with a spinal cord injury and paralysis. Which of the following nursing actions are appropriate? (Select all that apply.) Massage over erythematous bony prominences. Implement turning schedule every 4 hr. Use pillows to keep heels off the bed surface. Keep the client's skin dry with powder. Minimize skin exposure to moisture.

Use pillows to keep heels off the bed surface. Minimize skin exposure to moisture is correct.

A patient with a paraplegia resulting from a T10 spinal cord injury has a neurogenic reflex bladder. When the nurse develops a plan of care for this problem, which nursing action will be most appropriate? a. Teaching the patient how to self-catheterize b. Assisting the patient to the toilet q2-3hr c. Use of the Credé method to empty the bladder d. Catheterization for residual urine after voiding

a. Teaching the patient how to self-catheterize Rationale: Because the patient's bladder is spastic and will empty in response to overstretching of the bladder wall, the most appropriate method is to avoid incontinence by emptying the bladder at regular intervals through intermittent catheterization. Assisting the patient to the toilet will not be helpful because the bladder will not empty. The Credé method is more appropriate for a bladder that is flaccid, such as occurs with a reflexic neurogenic bladder. Catheterization after voiding will not resolve the patient's incontinence.

Nurse is assessing a patient who has a spinal cord injury?Which should the nurse include in the nervous system assessment to determine the extent of the patient's injury?select all that apply. a. vital sign b. romberg test c. plantar reflexes d. bilatereal hand grasps e. description of trauma

a. vital sign c. plantar reflexes d. bilatereal hand grasps e. description of trauma the assessment to determine the level of spinal cord injury includes analyzing the -vital sign, plantar reflexes, bilatereal hand grasp, description of trauma.Romberg test must be performed while standing therefore not suitable for unstable patient

A nurse is developing a plan of care for a client who has a spinal fracture and complete spinal cord transection at the level of C5. Which of the following rehabilitation goals should the nurse add to the client's plan of care? Ability to achieve independent transfer from bed to wheelchair Independent control of bowel and bladder function Use of a wheelchair with a chin or mouth stick Ability to self-feed with the use of adaptive equipment

Ability to self-feed with the use of adaptive equipment A client who has a spinal cord transection at the level of the fifth cervical vertebrae should have full neck, partial shoulder, back, biceps, and gross elbow movements. A realistic rehabilitation goal for the client is the ability to feed himself with the use of adaptive equipment.

A nurse is providing teaching to a client who has seizures and a new prescription for phenytoin. Which of the following information should the nurse provide? Phenytoin turns urine blue. Alcohol increases the chance of phenytoin toxicity. Avoid flossing the teeth to prevent gum irritation. Take an antacid with the medication if indigestion occurs.

Alcohol increases the chance of phenytoin toxicity.

A nurse is assessing a client who has a spinal cord injury. Which of the following actions should the nurse take to monitor C4 function? A. Apply downward pressure while the client shrugs his shoulders upward. B. Apply resistance while the client lifts his legs from the bed. C. Ask the client to grasp an object and form a fist. D. Apply resistance while the client flexes his arms.

Apply downward pressure while the client shrugs his shoulders upward. This assessment monitors the motor function of C4 to C5.

Which are characteristics of the Brown-Séquard syndrome? Select all that apply. A. The injury affects the entire spinal cord. B. It is a type of injury that results from penetrating injuries. C. Pain sensation is lost on the same side of the body as the injury. D. Motor function is lost on the same side of the body as the injury. E. Light touch sensation is affected on the opposite side of the body from the injury.

B. It is a type of injury that results from penetrating injuries. D. Motor function is lost on the same side of the body as the injury. E. Light touch sensation is affected on the opposite side of the body from the injury. RATIONALE:Brown-Séquard syndrome is a type of spinal cord injury syndrome that results from penetrating injuries that cause hemisection of the spinal cord or injuries that affect half of the spinal cord. Motor function, proprioception (position sense), vibration, and deep touch sensations are lost on the same side of the body as the injury (ipsilateral). On the opposite side of the body (contralateral) from the injury, the sensations of pain, temperature, and light touch are affected due to spinal nerve tract crossing.

The nurse is caring for a client who begins to experience seizure activity while in bed. Which action by the nurse would be contraindicated? A. loosening restrictive clothing B. restraining the clients limbs C. removing the pillow and raising padded side rails D. positioning the client to the side, if possible, with the head flexed forward

B. restraining the clients limbs

A male patient has a pinal cord injury at L 1-2 . Which clinical manifestation of the patient's injury is the nurse likely to observe before spinal shock resolves? A. opoiod analgesic Iv for foot pain B. able to balance in sitting position C. unresponsive quadriceps muscle D. requites asssist control ventilation

C. unresponsive quadriceps muscle during spinal shock neuromuscular function is lost below the level of the injury along with hyporeflexia and loss of sensation. So the pt will not be able to sit until the pinal shock resolves.

A nurse is reinforcing discharge instruction for a client following a laminevtomy. Which of the following instruction should the nurse include? -Sit in straight-back chairs -Sleep on a soft mattress -Walk around at least every 3 hr when on a long trip - Bend at the waist when lifting objects

Sit in straight-back chairs.

A nurse is teaching a client who has a new prescription for phenytoin. The nurse should instruct the client to monitor for and report which of the following adverse effects of this medication? A. Metallic taste B. Diarrhea C. Skin rash D. Anxiety

Skin rash

A patient with a neck fracture at the C5 level is admitted to the intensive care unit (ICU) following initial treatment in the emergency room. During initial assessment of the patient, the nurse recognizes the presence of spinal shock on finding a. hypotension, bradycardia, and warm extremities. b. involuntary, spastic movements of the arms and legs. c. the presence of hyperactive reflex activity below the level of the injury. d. flaccid paralysis and lack of sensation below the level of the injury.

d. flaccid paralysis and lack of sensation below the level of the injury. Rationale: Clinical manifestations of spinal shock include decreased reflexes, loss of sensation, and flaccid paralysis below the area of injury. Hypotension, bradycardia, and warm extremities are evidence of neurogenic shock. Involuntary spastic movements and hyperactive reflexes are not seen in the patient at this stage of spinal cord injury.

A home health nurse is caring for a client who is quadriplegic following a spinal cord injury and who is adjusting to the home environment. Which of the following client statements indicate the client is adapting? A. "My wife tries to get me to go to the grocery store, but I don't like to go out much." B. "I am using the modified feeding utensils at every meal. I still spill, but I'm getting better." C. "My greatest pleasure each day is having a few beers every day." D. "I have all the equipment to take a shower, but I prefer a bed bath, because it is easier."

"I am using the modified feeding utensils at every meal. I still spill, but I'm getting better." The client is adapting to the physical condition and displays goal setting.

A nurse is teaching the family of a client who is receiving treatment for a spinal cord injury with a halo fixation device. Which of the following statements should the nurse make? A. "Turn the screws on the device once each day." B. "The purpose of this device is to immobilize the cervical spine." C. "Apply talcum powder under the vest to limit friction." D. The purpose of this device is to allow for neck movement during the healing process."

"The purpose of this device is to immobilize the cervical spine." A client who has an injury to the cervical spine can have a halo fixation device to provide immobilization of the head and neck for a period of 8 to 12 weeks.

The client with spinal cord injury suddenly experiences an episode of autonomic dysreflexia. After checking vital signs, which immediate action should the nurse take? 1. raise the head of the bed and remove the noxious stimulus 2. lower the head of the bed and remove the noxious stimulus 3. lower the head of the bed and administer an antihypertensive agent

1. raise the head of the bed and remove the noxious stimulus

A patient has impairments from a SCI at C4 classified as incomplete C on the American Spinal Injury Association, (ASIA) Impairment Sclae. Which patient assessment is the nurse likely to observe in this patient? A. poor propricopetor in the legs B. poor peristalsis in the intestines C. Absent gag and blinking reflexes D. Absent bladder fulness sensation

B. poor peristalsis in the intestines A patient who has a SCI has neurologic impairment to all extremities and the diaphragm. However, because the injury is C on the ASIA impairment Scale, sensory function can be intact but motor function will be impaired significantly or absent.the patient can lose moderate to complete peristatlic action in the intestines but should reatine the ability to sense bladder fulnessand the position of the legs.

When planning care for a patient with a C5 spinal cord injury, which nursing diagnosis is the highest priority? A) Risk for impairment of tissue integrity caused by paralysis B) Altered patterns of urinary elimination caused by quadriplegia C) Altered family and individual coping caused by the extent of trauma D) Ineffective airway clearance caused by high cervical spinal cord injury

Correct Answer(s): D 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.

A nurse is caring for a client who has a C4 spinal cord injury. Which of the following should the nurse recognize the client as being at the greatest risk for? A. Neurogenic shock B. Paralytic ileus C. Stress ulcer D. Respiratory compromise

D. Respiratory compromise Using the airway, breathing, and circulation (ABC) priority-setting framework, the greatest risk to the client with an SCI at the level of C4 is respiratory compromise secondary to involvement of the phrenic nerve. Maintenance of an airway and provision of ventilatory support as needed is the priority intervention.

A nurse is caring for a client who has been placed in halo traction to immobilize his cervical spine. Which of the following actions should the nurse take? - Elevate the foot of the bed -Elevate the head of the bed -Apply a pelvic girdle -Place the client in a supine position

Elevate the head of the bed

A rehabilitation nurse is caring for a client who has had a spinal cord injury that resulted in paraplegia. After a week on the unit, the nurse notes that the client is withdrawn and increasingly resistant to rehabilitative efforts by the staff. Which of the following actions should the nurse take? A. Inform the client that privileges are related to participation in therapy. B. Limit visiting hours until the client begins to participate in therapy. C. Allow the client to control the timing and frequency of the therapy. D. Establish a plan of care with the client that sets attainable goals.

Establish a plan of care with the client that sets attainable goals. The nurse should develop a plan of care for this client with mutually set goals. This action invests the client in the rehabilitation process, which encourages feelings of ownership for it, and sees the goals as more attainable.

The nurse is watching for indications of autonomic dysreflexia in a client who sustained a spinal cord injury in a fall from a roof. Which sign/symptom of this complication should the nurse monitor closely? Constricted pupils Tachycardia Hypotension Nasal stuffiness

Nasal stuffiness RATIONALE:Autonomic dysreflexia, a complication of spinal cord injury, is a neurological emergency and must be treated immediately to prevent hypertensive stroke. It generally occurs after spinal shock resolves in the presence of injuries above T6 and in cervical lesions. It is commonly caused by visceral distention resulting from bladder distention or fecal impaction. Clinical manifestations include sudden onset of severe throbbing headache, severe hypertension, bradycardia, flushing above the level of injury, pale extremities below the level of injury, nasal stuffiness, nausea, dilated pupils, blurred vision, sweating, piloerection (gooseflesh), restlessness, and a feeling of apprehension.

A nurse working on a medical unit is caring for a client who is prescribed seizure precautions. Which of the following interventions should the nurse include in the client's plan of care? Obtain IV access. Keep the lights on when the client is sleeping. Place the client's bed in the high position. Keep a padded tongue blade available at the client's bedside.

Obtain IV access. The nurse should obtain IV access as a precaution so the client can receive IV medications in the event of a seizure.

A nurse is caring for a client who has had a spinal cord injury at the level of the T2-T3 vertebrae. When planning care, the nurse should anticipate which of the following types of disability? Paresthesia Hemiplegia Quadriplegia Paraplegia

Paraplegia Paraplegia, or paralysis of both legs, is seen after a spinal cord injury below T1.

A nurse is caring for a client who has quadriplegia from a spinal cord injury and reports having a severe headache. The nurse obtains a blood pressure reading of 210/108 mm Hg and suspects the client is experiencing autonomic dysreflexia. Which of the following actions should the nurse take first? Administer a nitrate antihypertensive. Assess the client for bladder distention. Place the client in a high-Fowler's position. Obtain the client's heart rate.

Place the client in a high-Fowler's position. The client who is experiencing autonomic dysreflexia is at risk for a cerebrovascular accident resulting from severe hypertension. According to the safety and risk reduction priority setting framework, the nurse's initial action should be to place the client in a high-Fowler's position to assist in providing immediate reduction in blood pressure and intracranial pressure.

A nurse is caring for a client who has a spinal cord injury and suspects the client is developing autonomic dysreflexia. Which of the following actions should the nurse take first? Check the client for a fecal impaction. Examine the client for areas of skin breakdown. Check the client's bladder for distention. Place the client in a sitting position.

Place the client in a sitting position. The nurse should use the least invasive intervention first. Therefore, the nurse should place the client in a sitting position to decrease the manifestation of hypertension.

A nurse is caring for a child who is having a tonic-clonic seizure and vomiting. Which of the following actions is the nurse's priority? Place a pillow under the child's head. Position the child side-lying. Loosen restrictive clothing. Clear the area of hazards.

Position the child side-lying.

A nurse is caring for a client who has a spinal cord injury at T-4. The nurse should recognize that the client is at risk for autonomic dysreflexia. Which of the following interventions should the nurse take to prevent autonomic dysreflexia? -Monitor for elevated blood pressure. - Provide analgesia for headaches. - Prevent bladder distention. - Elevate the client's head.

Prevent bladder distention.

A nurse is creating a plan of care for a client who has a history of tonic-clonic seizure disorder. Which of the following interventions should the nurse include? (Select all that apply.) Provide a suction setup at the bedside. Elevate the side rails near the head when the client is in bed. Place the bed in the lowest position. Keep an oxygen setup at the bedside. Furnish restraints at the bedside.

Provide a suction setup at the bedside. Elevate the side rails near the head when the client is in bed. Place the bed in the lowest position. Keep an oxygen setup at the bedside.

A patient experienced injury to the spinal cord in the cervical region, with paralysis and loss of sensory perception in both legs and both arms. What term is used to describe this condition? Paraplegia Hemiplegia Homoplegia Quadriplegia

Quadriplegia Injury to the spinal cord in the cervical region with paralysis and the loss of sensory perception in both legs and both arms is quadriplegia. Paraplegia is paralysis of both legs. Hemiplegia is paralysis of one half of the body. Homoplegia is not used to describe paralysis in the body.

A nurse is caring for a client who has a spinal cord injury. The nurse suspects that the client has auntonomic dysreflexia. Which of the following actions should the nurse take first? - Check the client for a fecal impaction - Ensure the room temperature is warm - Check the client's bladder for distention. - Raise the head of the bed

Raise the head of the bed