Chapter 68: TBI and SCI
A nurse is caring for a client with L1-L2 paraplegia who is undergoing rehabilitation. Which goal is appropriate?
Establishing an intermittent catheterization routine every 4 hours SCI --> atonic/neurogenic bladder --> Foley placed immediately In rehabilitation, Foley removed due to high risk of catheter-associated UTI. Intermittent catherization needed to relieve bladder distention or risk of infection caused by retention of urine.
The nurse is caring for a client following a spinal cord injury who has a halo device in place. The client is preparing for discharge. Which statement by the client indicates the need for further instruction?
"I can apply powder under the liner to help with sweating." Powder can contribute to formation of pressure areas.
The nurse is caring for a client who is being assessed for brain death. Which are cardinal signs of brain death? Select all that apply.
Absence of brainstem reflexes Apnea Coma
A client with quadriplegia is in spinal shock. What finding should the nurse expect?
Absence of reflexes along with flaccid extremities
A client with a concussion is discharged after the assessment. Which instruction should the nurse give the client's family?
Look for signs of increased intracranial pressure
