NUR 2520 unit III & IV

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

A,D,E Hypotension- Lack of sympathetic input can cause a decrease in blood pressure. The nurse should monitor the client's BP and maintain an SBP of 90mm Hg or higher to adequately perfuse the spinal column. Polyuria- the nurse should assess the patient for bladder distension and inability to urinate due to ineffective function of bladder muscles. Hyperthermia- The nurse should monitor for hypothermia due to a lack of sympathetic input. Absence of bowel sounds- Spinal shock leads to decreased peristalsis, which could cause the patient to develop paralytic ileus. Weakened gag reflex- The nurse should monitor for difficulty swallowing, coughing, or drooling noted with oral intake.

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? A. ability to achieve independent transfer from bed to wheelchair B. Independent control of bowel and bladder function C. Use of a wheelchair with a chin or mouth stick D. 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 c-5 should have full neck, partial shoulder, back, biceps, and gross elbow movements. This is a realistic goal.

A nurse is preparing to administer medication to a patient who has Myasthenia Gravis. What actions should the nurse take before administering the medication?

Ask the patient to take a few sips of water. Clients who have Myasthenia Gravis, have weakness of the muscles of the face and throat, which increases risk for aspiration. Having the patient take sips of water first allows the nurse to check the patients ability to swallow.

A nurse is assessing a client who has Parkinson's disease. Which of the following manifestations should the nurse expect?

Bradykinesia. The nurse should expect to find bradykinesia or difficulty moving in a client who has Parkinson's disease.

A nurse is caring for a patient who has Parkinson's disease and is taking diphenhydramine 25mg po TID. What therapeutic outcomes should the nurse expect?

Decreased tremors

A nurse is presenting a patient who has multiple sclerosis (ms). The client reports symptoms of diplopia, dysmetria, and sensory change. What should the nurse do?

Implement a schedule to include periods of rest.

a nurse is caring for a patient who has a suspected diagnosis of myasthenia gravis. the provider prescribes a tensilion test. which of the following indicates a positive test?

Muscle contractions become progressively stronger.

a nurse is assessing a client who has bells palsy. which of the following should the nurse expect? A. Muscle distortion B. Pain behind the ear C. Hearing loss D. Facial twitching E. Impaired taste

Muscle distortion, facial twitching, impaired taste.

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 should the nurse take first?

Place the patient in high fowlers 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 patient in a high-fowlers position to assist in providing an immediate reduction in blood pressure and intracranial pressure.

A nurse suspects a client who has myasthenia gravis is experiencing a myasthenic crisis. Which of the following interventions should the nurse take ?

Prepare the patient for mechanical ventilation. A patient in a myasthenic crisis is at risk for loss of adequate respiratory function.

A nurse is caring for a patient with a T-4 spinal cord injury. Which of the following client findings should the nurse identify as an indication that the client is at risk for developing autonomic dysreflexia?

The clients bladder becomes distended. Autonomic dysreflexia can occur in clients with a spinal cord injury occurs at T-6 or above. Autonomic dysreflexia happens when there is irritation, pain, or stimulus to the nervous system below the level of injury. There are many kinds of stimulation that can lead to autonomic dysreflexia such as, catheter changes, a distended bladder or bowel, enemas, and sudden changes in position. Manifestations include severe headache, elevated blood pressure, and flushed face.

A nurse is caring for a patient who has a new diagnosis of Myasthenia Gravis. Which of the following manifestations should the nurse monitor?

Weakness. Generalized weakness of the diaphragmatic and intercostal muscles may produce respiratory distress or predispose the client to respiratory infections.