4/2: - Liver Disease - Intracranial Regulation - Increased Intracranial Pressure - Mobility - Spinal Cord Injury

B) A sign of increased intracranial pressure These vital signs show increased blood pressure with a wide pulse pressure, slow heart rate, and respirations that are irregular, all indicating possible significant increased intracranial pressure. Normal heart rate for an awake child at this age is 70-110. Normal blood pressure is 92-126/55-86. Normal respirations are 20 and regular. These vital signs are a sign of increased intracranial pressure. If it were a spinal cord injury, and neurogenic shock were suspected, the child would be hypotensive. Normal sleeping pulse at this age is 60-90.

A 10-year-old loses consciousness after being hit in the head with a bat at baseball practice. The child was not wearing a helmet. The last set of vital signs showed heart rate 48, blood pressure 148/74, and respiratory rate 28 and irregular. What does this vital signs assessment indicate to the nurse? A) Typical for a sleeping child at this age B) A sign of increased intracranial pressure C) Normal for this child D) A sign that this child has a spinal cord injury

B) Platform crutches Platform crutches are used for clients who are unable to bear weight on their wrists. A walker, axillary crutches, and Lofstrand crutches all require the use of the wrists.

A 34-year-old mother of three sustained a right distal radial fracture and a left tibia fracture. The nurse and physical therapist will teach the client to use which mobility aide(s)? A) Lofstrand crutches B) Platform crutches C) Walker D) Axillary crutches

C) Low phosphorus (P) levels Low phosphorus levels may indicate a lack of vitamin D, which is affected by diet. High CK levels occur after muscle damage. High growth hormone levels may indicate acromegaly or gigantism. High calcitonin levels may indicate a parathyroid tumor.

A 68-year-old client has decreased bone density. Which diagnostic test results will alert you to the need for dietary education? A) High calcitonin levels B) High creatine kinase (CK) levels C) Low phosphorus (P) levels D) High growth hormone (GH) levels

B) Assess pain management. Osteoarthritis seen in normal aging can lead to the formation of bone spurs that make movement painful. The nurse should assess pain management prior to implementing an exercise program, teaching relaxation exercises, or referring to a dietitian.

A 70-year-old client is diagnosed with bone spurs of the vertebral column. The nurse should plan which priority action? A) Implement low-level exercise program. B) Assess pain management. C) Teach relaxation techniques. D) Refer to a dietitian.

3. Passive range-of-motion exercises 1. Active range-of-motion exercises 4. Resistive exercises 2. Ambulation 5. Weight loss instruction If the muscles needed for walking have not been used, ambulation is accomplished in steps. The first step is passive range-of-motion (ROM) exercises performed by the nurse or therapist. Active ROM is performed by the patient. Next, resistive exercise engages muscles. These steps prepare the client for ambulation. Nutrition instruction for weight loss would be performed prior to discharge.

A 78-year-old client hospitalized with spinal fusion surgery has a BMI of 34. Chronologically organize interventions to minimize the effects of bed rest. 1. Active range-of-motion exercises 2. Ambulation 3. Passive range-of-motion exercises 4. Resistive exercises 5. Weight loss instruction

B) The extent of injury cannot yet be determined. With a spinal cord injury, there is an area of ischemia and edema. Because edema extends from the level of injury for two cord segments above and below the affected level, the extent of injury cannot be determined for up to 1 week. The client's complaint of it being harder to breathe could be evidence that extent of injury is becoming more obvious but will not be totally determined for a few more days. The client's complaint of it being harder to breathe may or may not indicate pneumonia or atelectasis. The complaint is not evidence that the client is improving.

A client admitted 3 days prior with an injury to the thoracic area of the spinal cord tells the nurse, "I'm getting worse. It's harder to breathe." What should the nurse suspect is occurring with this client? A) The client has atelectasis. B) The extent of injury cannot yet be determined. C) The client is improving. D) The client is developing pneumonia.

B) The client's symptoms indicated meningitis The client's manifestations of a sore neck, chills, fever, and photophobia are consistent with meningitis. Assessing for the Brudzinski sign is not a routine part of the physical assessment. This maneuver is not done to assess for neck range of motion or optic nerve functioning.

A school-age child is experiencing photophobia, a sore neck, chills, and fever. During a physical assessment, the nurse uses the technique in the Exhibit. Why did the nurse use this technique when assessing the client? A) It is a routine part of the physical assessment. B) The client's symptoms indicated meningitis C) The nurse was assessing range of motion of the neck. D) The nurse was assessing optic nerve functioning.

C) Ineffective Breathing Pattern Since the client sustained the neck injury 2 days prior, the full extent of the injuries cannot yet be determined. The client's rate of respirations should be between 12 and 20 per minute. Since the client is breathing irregularly at a rate of 8-10 breaths per minute, the client may need assisted ventilation or a tracheostomy. The nursing diagnosis priority for this client would be Ineffective Breathing Pattern. An Impaired Gas Exchange could occur because of the Ineffective Breathing Pattern and would be the second in priority for this client. Impaired Physical Mobility and Autonomic Dysreflexia could be addressed at a later time.

A client who sustained a cervical neck injury 2 days ago is demonstrating an irregular respiratory pattern with the rate of 8-10 breaths per minute. What would be a priority nursing diagnosis for the client at this time? A) Impaired Physical Mobility B) Autonomic Dysreflexia C) Ineffective Breathing Pattern D) Impaired Gas Exchange

B) The spinal cord injury is incomplete. C) These findings are consistent with Brown-Sequard syndrome. D) Hemisection of the spinal cord is likely. E) Some recovery of sensory function is higher. Hemisection of the spinal cord, usually caused by a penetrating trauma (gunshot, knife), causes sensory and motor deficits on opposite sides of the body because the spinal cord injury is incomplete. These findings are consistent with Brown-Sequard syndrome, which has the best prognosis of all the incomplete spinal cord syndromes. American Spinal Injury Association (ASIA) Impairment Scale (AIS) score of A indicates a complete spinal cord injury where no sensory or motor function is preserved in the sacral segments S4-S5

A client who sustained a gunshot wound has symptoms below the level of T-12 of ipsilateral motor paralysis, loss of proprioception and vibratory sense, and contralateral loss of pain and temperature sensation. Which assumptions are correct? Select all that apply. A) American Spinal Injury Association Impairment Scale score is A. B) The spinal cord injury is incomplete. C) These findings are consistent with Brown-Sequard syndrome. D) Hemisection of the spinal cord is likely. E) Some recovery of sensory function is higher.

A) Loop diuretics C) Anticonvulsants D) Histamine H2 antagonists E) Antipyretics Medications play an important role in the management of IICP. Loop diuretics are commonly used to reduce ICP. Antipyretics such as acetaminophen are used alone or in combination with a hypothermia blanket to treat hyperthermia. Anticonvulsants are often required to manage seizure activity associated with brain injury and IICP. Gastrointestinal prophylaxis with intravenous histamine H2 antagonists are often used because clients with IICP are at increased risk for developing stress gastritis and ulcers. Antibiotics are not routinely prescribed as treatment for IICP.

A client with a head injury is demonstrating signs of increased intracranial pressure (IICP). Which classifications of medications should the nurse prepare to administer to this client? Select all that apply. A) Loop diuretics B) Antibiotics C) Anticonvulsants D) Histamine H2 antagonists E) Antipyretics

C) Platelets Ferrous sulfate and folic acid are given as indicated to treat anemia. Vitamin K may be ordered to reduce the risk of bleeding. When bleeding is acute, packed RBCs, fresh frozen plasma, or platelets may be administered to restore blood components and promote hemostasis.

A client with liver cirrhosis begins to drain bright red blood through the nasogastric tube. What should the nurse prepare to administer to this client? A) Vitamin K B) Ferrous sulfate C) Platelets D) Folic acid

A) Presence of portal hypertension. D) Sodium and water retention. Ascites is the accumulation of plasma-rich fluid in the abdominal cavity. Although portal hypertension is the primary cause of ascites, decreased serum proteins and increased aldosterone also contribute to the fluid accumulation. Hypoalbuminemia (low serum albumin) decreases the colloidal osmotic pressure of plasma. This pressure normally holds fluid in the intravascular compartment, but when the plasma colloidal osmotic pressure decreases, fluid escapes into extravascular compartments. Hyperaldosteronism (an increase in aldosterone) causes sodium and water retention, contributing to ascites and generalized edema.

A client with liver disease presents to the hospital with severe ascites. The nurse caring for the client understands that the pathophysiology involved in the development of ascites includes: Select all that apply. A) Presence of portal hypertension. B) Presence of hyperalbuminemia. C) Increased colloidal osmotic pressure. D) Sodium and water retention. E) Presence of hypoaldosteronism.

A) Assess airway, breathing, and circulation. The GCS (Glasgow Coma Scale) is a standardized system for assessment of consciousness. A score of 15 indicates full alertness and a score of 8 or less is usually indicative of coma; the lowest possible score is 3. The client's score is low so the nurse should follow the ABCs (airway, breathing, and circulation) of care in this case. Treating the client's pain, taking a history, and assessing the patency of the Foley catheter are done only after the airway is clear and the client is breathing.

A newly admitted client with increased intracranial pressure caused from a head injury has a Glasgow Coma Scale (GCS) score of 6. Which interventions should the nurse prepare to implement? A) Assess airway, breathing, and circulation. B) Assess patency of the Foley catheter. C) Treat the client's pain. D) Get a complete history from the client.

A) Excess Fluid Volume he client experiencing shortness of breath, edema, and hypertension should have a care plan for fluid volume excess. Hypertension, shortness of breath, and edema are manifestations of fluid excess. Hypotension and dry mucous membranes are associated with deficient fluid volume. Ineffective Tissue Perfusion would be the appropriate diagnosis for a client experiencing cyanosis or tissue necrosis. Edema can cause an alteration in skin integrity, but there is no evidence of such problems with this client.

A nurse is caring for a client who was recently admitted for treatment of cirrhosis. The client is currently experiencing BP of 200/100, +3 pitting edema, and shortness of breath. Which diagnosis should the nurse select as a priority for this client? A) Excess Fluid Volume B) Ineffective Tissue Perfusion C) Deficient Fluid Volume D) Impaired Skin Integrity

B) Decreased clotting factor levels due to impaired clotting mechanisms C) Hyperglycemia due to disrupted glucose metabolism Impaired function of liver cells has multiple effects. Impaired protein metabolism with decreased production of albumin and clotting factors occurs. Low albumin levels contribute to edema in peripheral tissues and ascites (accumulation of fluid in the abdomen), as plasma oncotic pressure is reduced, not increased. Impaired clotting-factor production increases the risk for bleeding. Disrupted glucose metabolism and storage may result in hyperglycemia. Also, serum vitamin K is decreased due to impaired absorption of fat-soluble vitamins.

A nurse is caring for a client with end-stage liver disease. Which hematological alterations might the nurse anticipate with this client? Select all that apply. A) Elevated serum albumin levels due to increased protein synthesis B) Decreased clotting factor levels due to impaired clotting mechanisms C) Hyperglycemia due to disrupted glucose metabolism D) Increased serum vitamin K due to impaired clearance of fat-soluble vitamins E) Increased plasma oncotic pressure due to impaired protein metabolism

B) Rest, ice, compression and elevation (RICE) for ankle sprain. RICE is used to decrease swelling and pain for ankle sprain. Parkinson's disease usually presents with tremors in clients over 50. Scoliosis is an abnormal curvature of the spine. There is no information suggesting scoliosis. Gout affecting mobility is caused by uric acid buildup, usually in a joint in the toe.

A preadolescent patient who fell from a balance beam in Physical Education class reports ankle pain. The nurse assesses edema and ecchymosis. What initial cause and intervention will be anticipated? A) Neurological evaluation for Parkinson's disease B) Rest, ice, compression and elevation (RICE) for ankle sprain. C) Brace fitting for scoliosis D) Colchicine for gout

C) Protect the client's neck and head from any movement. Guidelines for emergency care are avoiding flexing, extending, or rotating the neck; immobilization of the neck; securing the head; maintaining the client in the supine position; and transferring from the stretcher with backboard in place to the hospital bed. This client is unconscious, and the nurse must protect the neck from any (or any further) damage. If the client vomits, the nurse should utilize the log-roll technique to turn the client while keeping the head, neck, and spine in alignment. The client is breathing; however, if a change in respirations were to occur, the airway should be opened using the jaw thrust maneuver. Rousing the client by shaking could cause damage to the spinal cord.

A school nurse is treating a school-age child who has fallen down a flight of stairs. The child is breathing but unconsciousness. After calling the ambulance, what should the nurse do? A) Open the airway using the head tilt maneuver. B) Try to rouse the client by gently shaking the shoulders. C) Protect the client's neck and head from any movement. D) Place the client on the side to prevent aspiration.

C) Stabilization of the neck and spinal cord The danger of death from a spinal cord injury is greatest when there is damage to or transection of the upper cervical region. All people who have sustained trauma to the spine should be treated as though they have a spinal cord injury by stabilizing the neck and spinal cord. Assessment of urine output can be delayed. Assessing blood pressure is an intervention for all clients brought into the Emergency Department. An intravenous access line is necessary, but the stabilization of the neck and spinal cord is of first priority.

An adolescent is brought into the Emergency Department with injuries sustained from a motor vehicle crash. What should the nurse ensure while caring for this client? A) An adequate urine output B) Stable blood pressure C) Stabilization of the neck and spinal cord D) Intravenous access line

B) Dual energy x-ray absorptiometry C) Bone mineral density D) Quantitative ultrasound Tests used to aid in the diagnosis of osteoporosis include dual energy x-ray absorptiometry, quantitative ultrasound, and bone mineral density. Computed tomography and magnetic resonance imaging are done to aid in the diagnosis of arthritis, intervertebral disk disease, musculoskeletal trauma, muscle tears, osteomyelitis, and bone tumors.

An older client is demonstrating signs of osteoporosis. The nurse should instruct the client on which tests to aid in the diagnosis of this disorder? Select all that apply. A) Magnetic resonance imaging B) Dual energy x-ray absorptiometry C) Bone mineral density D) Quantitative ultrasound E) Computed tomography

A) Skeletal muscle attached to bones via tendons is performing correctly. Contraction of skeletal muscle attached to bones via tendons creates movement. Smooth muscle is not attached to bones. Cartilage is not vascular. The axial skeleton is not part of the lower extremities.

During the assessment of a client, the nurse finds that the client's lower extremities are both warm, sensation is intact, and motion is unrestricted. What does this finding suggest to the nurse? A) Skeletal muscle attached to bones via tendons is performing correctly. B) Smooth muscle attached to bones via ligaments will require further assessment. C) Cartilage connecting bones has a good blood supply. D) Muscle connecting the axial skeleton is compromised

B) Variations in alcohol metabolism C) Stress due to socioeconomic factors Alcohol consumption is the sixth-leading cause of death for Native Americans, particularly Alaskans. It is thought that contributing factors include variations in alcohol metabolism, socioeconomic factors that lead to stress, and, consuming alcohol without food. Climate and pollution are not factors.

The community health nurse is planning education for a group of individuals from Alcoholics Anonymous on the risk factors for liver disease. The group has a high number of Native Americans in attendance. What should the nurse explain as the reasons for the high incidence of cirrhosis in this ethnic group? Select all that apply. A) Pollution B) Variations in alcohol metabolism C) Stress due to socioeconomic factors D) Consuming alcohol with food E) Climate

D) Hemorrhoids Obstruction to portal blood flow causes a rise in portal venous pressure, resulting in splenomegaly, ascites, and dilation of collateral venous channels predominately in the paraumbilical and hemorrhoidal veins and the cardia of the stomach, and extending into the esophagus. Bleeding gums indicate insufficient vitamin K production in the liver. Muscle wasting is commonly associated with the poor nutritional intake seen in clients with cirrhosis. Hypothermia is an unrelated finding.

The family of a client with cirrhosis of the liver asks what symptoms they need to look for while the client is being cared for in their home. What should the nurse teach the family that indicates portal hypertension in this client? A) Muscle wasting B) Hypothermia C) Bleeding gums D) Hemorrhoids

A) "Bone pain in children is caused from the pulling of muscles when bones grow quickly." The rapid bone growth of childhood may lead to "growing pains" as muscles are pulled when bones grow quickly. Non-specific bone pain in a child is not a symptom that needs further investigation and does not need to be reported to the physician. Bone pain does not mean that the child needs to rest more. Non-specific bone pain does not mean that there is a disease process somewhere else in the body.

The mother of a preadolescent client is concerned because the child often reports non-specific "bone pain." What can the nurse respond to this mother? A) "Bone pain in children is caused from the pulling of muscles when bones grow quickly." B) "The child needs to rest more when the bones hurt." C) "Non-specific bone pain means there is a disease process somewhere else in the body." D) "It is a symptom that needs further investigation and will be reported to the physician."

C) Brain stem impairment Brain function deterioration usually follows a predictable progression in which higher levels of function are impaired first and progress to impairment of more primitive functions. Altered level of consciousness (LOC) is an early manifestation of the deterioration of the function of the cerebral hemispheres. Seizure disorders have various types of motor postures. Structures in the brainstem have characteristic changes in motor function. Evidence of brainstem involvement includes decerebrate posturing that is distinguished by rigid extension. Corticospinal tract impairment is characterized by decorticate posturing which is rigid flexion.

The nurse becomes concerned when a client who sustained a head injury from a motor vehicle crash begins to demonstrate the following posture. What does this posture suggest to the nurse about the client's brain functioning? A) Altered level of consciousness B) Developing a seizure disorder C) Brain stem impairment D) Corticospinal tract impairment

B) 5-year-old client for ankle pain after a fall from a horse C) 38-year-old client for headache pain after a skiing accident D) 70-year-old client for back pain after laminectomy E) 22-year-old client for knee pain who is allergic to naproxen Aspirin is indicated for clients with rheumatoid arthritis who have no other contraindications. The healthcare provider should be questioned when ordering aspirin for a child or for clients with a risk of bleeding. A fall, a skiing accident, and laminectomy surgery all cause a risk of bleeding. Aspirin should not be given to a client who is allergic to non-steroidal anti-inflammatory drugs.

The nurse contacts the provider to question an order to administer 1,000 mg aspirin to which clients? Select all that apply. A) 68-year-old client for hand pain who has rheumatoid arthritis B) 5-year-old client for ankle pain after a fall from a horse C) 38-year-old client for headache pain after a skiing accident D) 70-year-old client for back pain after laminectomy E) 22-year-old client for knee pain who is allergic to naproxen

C) Lordosis is commonly seen in the gait and posture assessment of a pregnant woman. An exaggerated concave curvature of the lumbar spine is lordosis and is seen in the gait and posture assessment of pregnant women or obese clients. Scoliosis is not normal. A range-of-motion assessment, joint assessment, or interview will not detect lordosis.

The nurse detects an exaggerated concave curvature of the lumbar spine of a client. Which conclusion about this assessment is correct? A) Abnormal kyphosis is noted during range-of-motion assessment of a child. B) Normal scoliosis is observed during the joint assessment of an older man. C) Lordosis is commonly seen in the gait and posture assessment of a pregnant woman. D) Crepitus is commonly found during the assessment interview of a middle-aged woman.

B) Avoid sharing needles. Hepatitis B is contracted through contaminated blood and body fluids. The client will increase the risk of contracting hepatitis B by sharing needles. Hepatitis A is transmitted via the fecal-oral route. Laënnec's cirrhosis is the result of alcohol and hepatitis B and C. Contaminated food and water causes hepatitis A, not B

The nurse determines that a client is at risk for contracting hepatitis B because of intravenous drug use. What should the nurse teach to reduce the client's risk for this health problem? A) Avoid contaminated food and water. B) Avoid sharing needles. C) Avoid alcohol consumption. D) Wash hands frequently, as the disease is transmitted via the fecal-oral route.

B) Encourage the family to express feelings. While families may need education about seat belts and sources of support, it is not the optimal time to implement such teaching at this point in the crisis. It is optimal to find out the family's perception of what is going on and what they feel their needs are. The best way to determine this is to encourage them to express their feelings. Timelines for visitation are appropriate but are not the priority.

The nurse identifies the diagnosis of Interrupted Family Processes for a child who sustained a brain injury during an automobile accident. Which intervention would support this diagnosis? A) Teach the family the importance of using seat belts. B) Encourage the family to express feelings. C) Refer the family to support services in the community. D) Explain rules for visiting in the Intensive Care Unit.

C) Prevent cord damage from ischemia and edema High-dose steroid protocol using methylprednisolone must be implemented within 8 hours of the injury to improve neurologic recovery. Clinical research indicates that the use of this adrenocorticosteroid is effective in preventing secondary spinal cord damage from edema and ischemia. This medication may cause hyperglycemia if the client also has a diagnosis of diabetes. This medication is not provided to improve respirations or improve the level of consciousness.

The nurse in the Emergency Department is preparing to administer methylprednisolone to a client with a spinal cord injury. What effect will this medication have on the client? A) Cause an increase in blood glucose level B) Improve the level of consciousness C) Prevent cord damage from ischemia and edema D) Improve the ability to be adequately ventilated

A) Passive range-of-motion exercises Range-of-motion exercises would not be done. It is imperative to keep the child with increased intracranial pressure quiet, with as little stimulation as possible. Hourly vital signs and neuro checks are appropriate to watch for changes in this child's condition. The head is elevated 30° to help to decrease increased intracranial pressure. Oxygen should be ordered to keep the child's O2 saturation above 95%.

The nurse is caring for a child with decreased level of consciousness secondary to increased intracranial pressure (IICP) from a head trauma. Which order from the healthcare provider should the nurse question? A) Passive range-of-motion exercises B) Elevating the head of the bed to 30° C) Vital signs and neuro checks every hour D) Administering oxygen at 2 L nasal cannula to keep saturation above 95%

B) "Increasing brain pressure decreases the amount of blood flow to the brain itself." The Monroe-Kellie hypothesis states that a dynamic equilibrium exists among the three components (brain, cerebrospinal fluid, and blood) of the skull. A change in the volume of any component risks a decrease in the remaining components to maintain normal intracranial pressures. The other statements by the nurse would be incorrect according to this hypothesis.

The nurse is caring for a client in the neurological ICU with head trauma. The client is being monitored for increased intracranial pressure (IICP). Using the Monroe-Kellie hypothesis as a basis for explanation, which comment by the nurse to the client's family would be most appropriate? A) "There is nothing that can be done." B) "Increasing brain pressure decreases the amount of blood flow to the brain itself." C) "The pressure in the brain is increasing because the brain is shrinking." D) "Because there is more pressure in the brain, the blood flow is also increasing."

B) Drinks a six-pack of beer each evening. Risk factors for the development of cirrhosis of the liver include excessive alcohol intake. Smoking, ingestion of salads, and exercise are not risk factors for the development of this health problem.

The nurse is caring for a client with cirrhosis of the liver. Which information in the client's health history supports this diagnosis? A) Smokes two packs of cigarettes per day. B) Drinks a six-pack of beer each evening. C) Eats salads for lunch every day. D) Plays on an adult softball team several times a week.

B) "If our child develops an altered level of consciousness, we will notify the doctor." An altered level of consciousness would be a symptom of shunt malfunction and increasing intracranial pressure. In most children, by age 8, the cranial suture lines have fused, and the fontanelles are closed, so a bulging soft spot, expanding head size, or sunset eyes would not be common symptoms of shunt malfunction and an increase in intracranial pressure.

The nurse is caring for an 8-year-old child who will be discharged from the hospital after receiving a ventriculoperitoneal (VP) shunt as treatment for IICP. The nurse has taught the parents to monitor the child for shunt malfunction. Which statement by the parents regarding when to notify the healthcare provider indicates that learning goals have been met? A) "If our child has a bulging soft spot, we will call the doctor." B) "If our child develops an altered level of consciousness, we will notify the doctor." C) "If we notice our child's head is expanding, we will notify the doctor." D) "If our child develops sunset eyes, it will be important to call the doctor."

B) Normal serum bilirubin levels Normal bilirubin levels would indicate that the transplanted liver is functioning correctly. Normal pupil reaction, leg movement, and moist mouth membranes are all normal findings for any postoperative client.

The nurse is caring for client recovering from a liver transplant necessitated by cirrhosis of the liver. Which postoperative outcome would be a priority for this client? A) Moist membranes of the mouth B) Normal serum bilirubin levels C) Ability to move the legs D) Normal pupil reaction

A) Increased abdominal girth Ascites is the accumulation of the fluid in the abdomen, and is a result of liver failure. The client with ascites would have an increased abdominal girth. Jaundice is manifested as yellow-tinged skin, and is the result of hepatic disorders. The client experiencing hepatic problems might have bleeding and bruising issues due to inadequate vitamin K. Obstructed biliary flow could be the cause of gallbladder pain

The nurse is concerned that a client with potential hepatic failure is at risk for developing ascites. Which assessment finding would indicate this development? A) Increased abdominal girth B) Gallbladder pain C) Yellow-tinged skin D) Bleeding and bruising easily

A) Limit the client's visitors. B) Teach family to speak softly and minimize touching. E) Keep the room dark and quiet. A dark, quiet room is important to reduce stimuli. Family members should be encouraged to talk to the client in a soft voice with minimal touching. Visitors should be limited. Care should be provided throughout the day for short periods of time to limit extended stress and stimulation. Elevating the head of the bed is important to reducing intracranial pressure but has no effect on stimulation.

The nurse is determining ways to decrease environmental stimuli for a client with increased intracranial pressure. What actions should the nurse take to support this client's care need? Select all that apply. A) Limit the client's visitors. B) Teach family to speak softly and minimize touching. C) Elevate the head of the bed. D) Provide all care quickly at one time to provide periods of rest. E) Keep the room dark and quiet.

B) The client is improving in ability to perform self-urinary catheterization. An ideal outcome for the client with bowel and bladder dysfunction as a result of a spinal cord injury would be for the client to attain appropriate bowel and bladder elimination habits. If the client's ability to perform self-urinary catheterization is improving, the interventions can be considered successful. The client with an indwelling urinary catheter receiving stool softeners every morning is not progressing toward bowel and bladder elimination habits. The client who had two episodes of impacted stool over the last week is not progressing in bowel elimination habits. The client who is limiting fluids to reduce the need to void is possibly hindering his health in order to avoid having to perform self-urinary catheterization.

The nurse is evaluating the effectiveness of interventions to address a client's bowel and bladder dysfunction as a result of a spinal cord injury. What would indicate that the interventions are successful? A) The client had two episodes of impacted stool over the last week. B) The client is improving in ability to perform self-urinary catheterization. C) The client is limiting fluids to reduce need to void. D) The client has an indwelling urinary catheter and is provided with stool softeners every morning.

B) Performs self-urinary catheterization every 4 hours while awake. C) Transfers to use bedside commode after breakfast to evacuate bowels. E) Maintains a high-fluid, high-fiber diet. Evidence that a bowel and bladder retraining program for a client with a spinal cord injury has been successful includes performing self-urinary catheterization every 4 hours while awake, transferring to the bedside commode to evacuate bowels after breakfast, and maintaining a high-fluid and high-fiber diet to prevent constipation. Evidence that this training has not been successful includes an episode of bladder incontinence and the need to impacted stool removed twice in 1 week.

The nurse is evaluating the success of a bowel retraining program with a client recovering from a lower motor neuron spinal cord injury. Which observations indicate that this teaching has been successful? Select all that apply. A) One episode of bladder incontinence in 8 hours B) Performs self-urinary catheterization every 4 hours while awake. C) Transfers to use bedside commode after breakfast to evacuate bowels. D) Two episodes of impacted stool in 1 weekE) Maintains a high-fluid, high-fiber diet.

A) Independent: injury prevention Instructing the patient to remove loose rugs in the home is an example of an independent nursing intervention aimed at injury prevention. Collaborative interventions involve another discipline-e.g., physical therapy. Preservative functioning interventions are collaborative efforts to limit the adverse effects of immobility. Promotion of comfort may involve pain medication or padding a splint. Although the family should be included in this instruction, it is not just directed at them.

The nurse is giving discharge instructions on removing loose rugs in the home to a client with a total hip replacement. This is an example of which type of nursing intervention? A) Independent: injury prevention B) Independent: preservative functioning C) Collaborative: promotion of comfort D) Collaborative: family instruction

D) Assess for a full bladder. E) Assess blood pressure every 2-3 minutes. An alteration in perfusion can be caused by autonomic dysreflexia, which is an emergency that requires immediate assessment and intervention. The nurse should continue to assess the client's blood pressure every 2-3 minutes in addition to elevating the head of the bed and removing TED hose to encourage the pooling of blood in the extremities and decrease the blood pressure. Once the blood pressure has stabilized or decreased, the nurse can then assess for the stimuli which caused the episode, such as a full bladder. Discussing future care needs when discharged is not a priority at this time, or an intervention for Alteration in Perfusion. Turning the client every 2 hours is not a priority at this time, or an intervention for Alteration in Perfusion.

The nurse is planning care for a client admitted with a high thoracic spinal cord injury. Which interventions would be appropriate for the nursing diagnosis of Alteration in Perfusion?Select all that apply. A) Discuss future care needs when discharged. B) Increase fluids to 3,000 mL per day. C) Turn and reposition every 2 hours. D) Assess for a full bladder.E) Assess blood pressure every 2-3 minutes.

A) Ensuring adequate oxygenation Ensuring adequate oxygenation to support brain function is the most important step in management of IICP. Although pain control, a calm environment, and vomiting (a sign of increased ICP) would be important, they are secondary to airway.

The nurse is planning care for a client with a head injury and increased intracranial pressure (IICP) from a motor vehicle crash. Which intervention is a priority for this client? A) Ensuring adequate oxygenation B) Maintaining a calm environment C) Monitoring for nausea and vomiting D) Controlling pain

A) Anxiety, illness, and pain can alter the ability to learn. C) Impulse transmission and reactions to stimuli are slower. E) Impairment in vision and hearing should be taken into consideration. In the older client, anxiety, illness, and pain can alter the ability to learn. Reflexes are less intense in an older client. Responses to stimuli are slower because of reduced impulse transmission. Many older adults have some impairment of hearing and visions, which should be taken into consideration when planning care. Reflex responses may slightly increase or decrease. Many older clients show a loss of the Achilles reflex, and the planar reflex may be difficult to elicit.

The nurse is planning care for an older client with a head injury sustained from a motor vehicle crash. Which information should the nurse keep in mind when planning this client's care? Select all that apply. A) Anxiety, illness, and pain can alter the ability to learn. B) Reflexes are less intense in an older client. C) Impulse transmission and reactions to stimuli are slower. D) The plantar and Achilles reflexes are hyperactive in this age group. E) Impairment in vision and hearing should be taken into consideration.

C) "I'm going to spend extra time discussing this with my Boy Scout troop because of their higher risk for spinal cord injury." The highest-risk population for spinal cord injuries is males between 16 and 30 years old. Riding motorcycles increases spinal cord injuries. Native Americans are the ethic group with the lowest risk of spinal cord injury. Using a seat belt is a major preventive action for an individual involved in a motor vehicle accident.

The nurse is presenting a talk on spinal cord injury for a community health fair. Which statement indicates that the attendees understand the risk factors and prevention methods associated with spinal cord injury? A) "There isn't much I can do to prevent a head injury when another vehicle hits my car." B) "As long as my grandson wears a helmet, he will be safe on his motorcycle." C) "I'm going to spend extra time discussing this with my Boy Scout troop because of their higher risk for spinal cord injury." D) "Due to their high risk, I'd like you to present this talk to the Native American population."

C) Pupils equal and reactive to light D) Oxygen saturation 93% via pulse oximetry Assessment areas include LOC; behavior; motor/sensory functions; pupillary size and reaction to light; and vital signs, including temperature. An elevated temperature with increased oxygen consumption further increases ICP. Pressure on the brainstem may compromise the function of protective mechanisms such as the gag reflex. Pupillary responses mirror the status of the midbrain and pons. Adequate air exchange is needed to keep oxygen and carbon dioxide levels within normal ranges and maintenance of acid-base balance is critical to reduce the risk of hypoxemia and IICP. An oxygen saturation level of 93% is within normal limits. A sluggish response to verbal stimuli could indicate increasing ICP.

The nurse is providing care to prevent a client recovering from a head injury from developing increased intracranial pressure (IICP). Which assessment information suggests that nursing care has been successful? Select all that apply. A) Body temperature elevated 1 degree in 4 hours B) Absent gag reflex C) Pupils equal and reactive to light D) Oxygen saturation 93% via pulse oximetry E) Sluggish response to verbal stimuli

B) MRI result C) Head CT scan with and without contrast D) Electroencephalogram E) Complete blood count of the cerebrospinal fluid Diagnosis of increased ICP is made on the basis of observation and neurologic assessment; even subtle changes can be clinically significant. Testing can include CT scan with and without contrast, MRI, electroencephalogram, and cerebrospinal fluid evaluation. Bronchoscopy is not performed routinely for a client with increased intracranial pressure

The nurse is reviewing results of diagnostic testing performed on a client with increased intracranial pressure (ICP) in preparation for an evaluation to be done by the neurosurgeon during morning rounds. Which diagnostic test results should be on the medication record for the physician's review? Select all that apply. A) Bronchoscopy results B) MRI result C) Head CT scan with and without contrast D) Electroencephalogram E) Complete blood count of the cerebrospinal fluid

A) The head of the bed should be elevated to 30 degrees. C) The family should use slow, gentle movements when repositioning the client. D) The client should be repositioned as needed. Patients with increased ICP should be repositioned slowly and with gentle movements, because rapid changes can cause the pressure to increase. The head of the bed should be elevated. The degree depends on the reaction of the client to the position; 30 degrees is usually appropriate, but this can vary by the client. Patients with IICP must not remain stationary, but position changes should be done less frequently than for other clients because turning, skin care, and passive range of motion exercises can elicit posturing, which also causes increased ICP.

While caring for a client with increased intracranial pressure (IICP), a family member asks to assist. What are appropriate interventions for the nurse to teach the family member? Select all that apply. A) The head of the bed should be elevated to 30 degrees. B) The client should remain in a supine position. C) The family should use slow, gentle movements when repositioning the client. D) The client should be repositioned as needed. E) Patients with ICP should remain in a stationary position.

A) Risk for Post-Trauma Syndrome The client's statement is unrealistic and is evidence of Risk for Post-Trauma Syndrome. Although the client with tetraplegia does have Impaired Physical Mobility and Self-Care Deficit, this statement is not evidence of those nursing diagnoses. There is no indication of Noncompliance.

You assess a young adult client that sustained a swimming accident, resulting in tetraplegia. The client makes eye contact with you and verbalizes, "I'm going to beat this and walk out of here." Which nursing diagnosis is best supported by this data? A) Risk for Post-Trauma Syndrome B) Impaired Physical Mobility C) Self-Care Deficit D) Noncompliance