Unit 6 and 7 prep Us

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 will change the vest liner periodically." "If a pin becomes detached, I'll notify the surgeon." "I can apply powder under the liner to help with sweating." "I'll check under the liner for blisters and redness."

"I can apply powder under the liner to help with sweating."

The nurse is admitting a client with heart failure. What client statement indicates that fluid overload was occurring at home? "I eat six small meals a day when I am hungry." "I've stopped eating foods with salt, though I miss the taste." "I'm having trouble going up the steps during the day." "My best time of the day is the morning."

"I'm having trouble going up the steps during the day."

The nurse is providing health education to a client who has a C6 spinal cord injury. The client asks why autonomic dysreflexia is considered an emergency. What would be the nurse's best answer? "The sudden increase in BP can raise the ICP or rupture a cerebral blood vessel." "The suddenness of the onset of the syndrome tells us the body is struggling to maintain its normal state." "Autonomic dysreflexia causes permanent damage to delicate nerve fibers that are healing." "The sudden, severe headache increases muscle tone and can cause further nerve damage."

"The sudden increase in BP can raise the ICP or rupture a cerebral blood vessel."

What is the normal pH of the blood? Why was Allen's blood pH below normal?

- 7.35-7.45; not able to exhale all the carbon dioxide

Why did Allen have dry skin and a fever upon admission to the hospital?

- Inability to regulate temperature and is in spinal shock cannot release heat

10. Why did Allen suffer from urinary incontinence?

- Neurogenic shock and the C5 damage eliminate the commands (sensory) causes involuntary contractions to empty it

What is the primary muscle of respiration? What nerve innervates this muscle?

- The primary muscle is the diaphragm; phrenic nerves (C3-C5 keep the diaphragm alive)-C4 or higher no breathing

5. Based upon the physical exam findings, which vertebral bone do you think was fractured? Give reasons for your answer. 3

-C5 the phrenic nerve is impacted; C6 lower the phrenic nerve is not usually impacted, -C4 or higher will need ventilation -C5: difficulty breathing, quadriplegia

Nursing Interventions: Medications s/e 6

-Dopaminergics: For example, Levodopa- Carbidopa, increases dopamine levels -• S/E Dyskinesia, confusion, dizziness, nausea, lightheadedness, insomnia, constipation, dry mouth, orthostatic hypotension. -• Monitor for wearing off "on off phenomenon" which is mobility to immobility. This occurs when the Pt has been on the drug for a long time. When this happens the Dr. may adjust the dose or time of administration, Or may prescribe a MAO-B Inhibitor. The MAO-B inhibitor decreases the breakdown of levodopa. -• May need adjunct medications like dopamine agonists, anticholinergics, COMT inhibitors, and MAO-B inhibitors.

9. By four days after the injury, some of Allen's signs and symptoms had changed. Allen's arm muscles were still flaccid, yet his leg muscles had become spastic and exhibited exaggerated stretch reflexes. Use your knowledge of motor neural pathways to explain these findings.

-The lower motor neuron is influenced neurons several location; the motor neurons regain excitable despite the motor neuron simulations; reflex can be there the sensory will not; the nerves are destroyed not coming back the ones below will come back

3. Why did Allen lose some sensation in his arms and all sensation from the upper trunk down?

-cervical injury -The loss of sensation in parts of his arms and from the upper trunk down suggests that the spinothalamic tracts and dorsal columns tract were damaged bilaterally at about the C5 segment (

Which of the following Types of Heart Failure occurs when the heart cannot supply enough blood to meet the body's metabolic needs?

-high output High output heart failure occurs when the body's need for blood is unusually high in a normally functioning heart.

What kinds of drugs are tolcapone and carbidopa/levodopa, and what teaching should the nurse provide about these drugs? 2

-nausea, hypotension, diarrhea - time every 8 hours

1. Upon admission to the hospital, Allen's breathing was rapid and shallow. Can you explain why? 2

-phrenic nerve was impacted -. Allen's spinal cord injury may have damaged parts of the spinal cord that transmit impulses through lower motor neurons to the breathing muscles - - i.e. the diaphragm and external intercostal muscles. The third through fifth cervical segments (C3 to C5) of the spinal cord supply

SPINAL CORD INJURY 1. Why did Allen's heart rate and blood pressure fall in this time of emergency (i.e. at a time when you'd expect just the opposite homeostatic responses)? 3

-spinal shock -. A fall in blood pressure (hypotension) could indicate that Allen is bleeding internally. --The result of this injury is spinal shock, a condition in which all spinal reflexes below the level of the lesion are temporarily silenced

B. Lumbar disc 6

1. Back pain radiating across buttock and down leg (along sciatic nerve) 2. Weakness of leg and foot on affected side 3. Numbness and tingling in toes and foot 4. Positive straight leg raise test: pain on raising leg 5. Depressed or absent Achilles reflex 6.Muscle spasm in lumbar region

C. Initial management 4

1. Pain killers 2. Muscle relaxants 3. Physical therapy 4. Epidural blocks

A. Cervical disc 3

1. Shoulderpain radiating down arm to hand 2. Weakness of affected upper extremity 3. Paresthesias and sensory disturbances

A nurse has reported for a shift at a busy burns and plastics unit in a large university hospital. Which client is most likely to have life-threatening complications? A 4-year-old scald victim burned over 24% of the body A 27-year-old male burned over 36% of his body in a car accident A 39-year-old female client burned over 18% of her body A 60-year-old male burned over 16% of his body in a brush fire

A 4-year-old scald victim burned over 24% of the body

Slipped Disc path 2

A.Herniation of nucleus pulposus or cushion between vertebrae B. Herniated portion puts pressure on spinal nerve

Which of the following medications or drug classes is most commonly used as an intervention for patients with heart failure?

ACE Inhibitors

A client presents to the ED reporting increasing shortness of breath. The nurse assessing the client notes a history of left-sided heart failure. The client is agitated and occasionally coughing up pink-tinged, foamy sputum. The nurse should recognize the signs and symptoms of what health problem? Right-sided heart failure Acute pulmonary edema Pneumonia Cardiogenic shock

Acute pulmonary edema

Which of the following interventions is most likely indicated during an exacerbation of heart failure?

Advanced Airway -In situations of severe pulmonary edema, an advanced airway (initiating intubation and ventilation) may be required.

The nurse is performing a physical assessment on a client suspected of having heart failure. The presence of what sound would signal the possibility of impending heart failure? An S3 heart sound Pleural friction rub Faint breath sounds A heart murmur

An S3 heart sound

A client has been experiencing increasing shortness of breath and fatigue. The health care provider has ordered a diagnostic test in order to determine what type of heart failure the client is having. What diagnostic test does the nurse anticipate being ordered? A chest x-ray An echocardiogram An electrocardiogram A ventriculogram

An echocardiogram

Which of the following medications or drug classes is most commonly used as an intervention for patients with heart failure?

Angiotensin II Receptor Blockers (ARBs)

A nurse who provides care on a burn unit is preparing to apply a client's ordered topical antibiotic ointment. What action should the nurse perform when administering this medication? Apply the new ointment without disturbing the existing layer of ointment Apply the ointment using a sterile tongue depressor Apply a layer of ointment approximately 1/16 inch thick Gently irrigate the wound bed after applying the antibiotic ointment

Apply a layer of ointment approximately 1/16 inch thick

A client arrives at the ED with an exacerbation of left-sided heart failure and reports shortness of breath. Which is the prioritynursing action? Administer angiotensin II receptor blockers Assess oxygen saturation Administer diuretics Administer angiotensin-converting enzyme inhibitors

Assess oxygen saturation

Which of the following medications or drug classes is most commonly used as an intervention for patients with heart failure? pt 2

Beta Blockers

A nurse is caring for a critically ill client with autonomic dysreflexia. What clinical manifestations would the nurse expect in this client? Respiratory distress and projectile vomiting Bradycardia and hypertension Tachycardia and agitation Third-spacing and hyperthermia

Bradycardia and hypertension

A client with a spinal cord injury has full head and neck control when the injury is at which level? C1 C2 to C3 C4 C5

C5

When assessing a client who has experienced a spinal injury, the nurse notes diaphragmatic breathing and loss of upper limb use and sensation. At what level does the nurse anticipate the injury has occurred? C3 C5 T6 L1

C5

A patient in severe pulmonary edema is being intubated by the respiratory therapist. What priority action by the nurse will assist in the confirmation of tube placement in the proper position in the trachea? Observe for mist in the endotracheal tube. Listen for breath sounds over the epigastrium. Call for a chest x-ray. Attach a pulse oximeter probe and obtain values.

Call for a chest x-ray.

A nurse is planning discharge education for a client who underwent a cervical discectomy. What strategies would the nurse assess that would aid in planning discharge teaching? Care of the cervical collar Technique for performing neck ROM exercises Home assessment of ABGs Techniques for restoring nerve function

Care of the cervical collar

A client with a C5 spinal cord injury has tetraplegia. After being moved out of the ICU, the client reports a severe throbbing headache. What should the nurse do first? Check the client's indwelling urinary catheter for kinks to ensure patency. Lower the HOB to improve perfusion. Administer PRN analgesia as prescribed. Reassure the client that headaches are expected during recovery from spinal cord injuries.

Check the client's indwelling urinary catheter for kinks to ensure patency.

The nurse has completed a head-to-toe assessment of a patient who was admitted for the treatment of heart failure (HF). Which of the following assessment findings should signal to the nurse a possible exacerbation of the patient's condition? Crackles are audible on chest auscultation. The patient's blood pressure (BP) is 144/99. The patient has put out 600 mL of dilute urine over the past 8 hours. Blood glucose testing reveals a glucose level of 158 mg/dL.

Crackles are audible on chest auscultation.

A client with severe burns is admitted to the intensive care unit to stabilize and begin fluid resuscitation before transport to the burn center. The nurse should monitor the client closely for what signs of the onset of burn shock? Confusion High fever Decreased blood pressure Sudden agitation

Decreased blood pressure

A client is admitted to the cardiac care unit for an electrophysiology (EP) study. What goal should guide the planning and execution of the client's care? Ablate the area causing the dysrhythmia. Freeze hypersensitive cells. Diagnose the dysrhythmia. Determine the nursing plan of care.

Diagnose the dysrhythmia.

Which of the following medications is most commonly added to the regimen for patients who fail to respond to conventional pharmacotherapy for heart failure?

Digoxin

Which of the following medications or drug classes is most commonly used as an intervention for patients with heart failure?

Diuretics Diuretics are used to decrease preload of the heart by promoting sodium and water loss thereby allowing the ventricles to contract more efficiently.

Which of the following tests or diagnostic tools is most applicable when considering heart failure interventions? pt2

Echocardiogram An echocardiogram uses high-frequency sound waves to produce a graphic image of the heart and is routinely used in the diagnosis of heart failure.

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 Managing spasticity with range-of-motion exercises and medications Establishing an ambulation program using short leg braces Preventing autonomic dysreflexia by preventing bowel impaction

Establishing an intermittent catheterization routine every 4 hours

Splints have been prescribed for a client who is at risk of developing foot drop following a spinal cord injury. The nurse should remove and reapply the splints when? At the client's request Each morning and evening Every 2 hours One hour prior to mobility exercises

Every 2 hours

A client has been admitted to a burn intensive care unit with extensive full-thickness burns over 25% of the body. After ensuring cardiopulmonary stability, what would be the nurse's immediate, priority concern when planning this client's care? Fluid status Risk of infection Nutritional status Psychosocial coping

Fluid status

Which position, movement, or direction is best used as an intervention for heart failure?

High fowlers position

A client is already being treated for hypertension. The doctor is concerned about the potential for heart failure, and has the client return for regular check-ups. What does hypertension have to do with heart failure? Hypertension causes the heart's chambers to enlarge and weaken. Hypertension causes the heart's chambers to shrink. Heart failure occurs when blood pressures drops. Hypertension in older males regularly leads to heart failure.

Hypertension causes the heart's chambers to enlarge and weaken.

Which New York Heart Association classification of heart failure (HF) has a poor prognosis and includes symptoms of cardiac insufficiency at rest? IV I II III

IV

The nurse caring for a client with a spinal cord injury notes that the client is exhibiting early signs and symptoms of disuse syndrome. Which of the following is the most appropriate nursing action? Limit the amount of assistance provided with ADLs. Collaborate with the physical therapist and immobilize the client's extremities temporarily. Increase the frequency of ROM exercises. Educate the client about the importance of frequent position changes.

Increase the frequency of ROM exercises.

A cardiac care nurse is caring for a client who is experiencing positive chronotropy. What effect should the nurse prepare for? Exacerbation of an existing dysrhythmia Initiation of a new dysrhythmia Resolution of ventricular tachycardia Increased heart rate

Increased heart rate

A client's burns have required a homograft. During the nurse's most recent assessment, the nurse observes that the graft is newly covered with purulent exudate. What is the nurse's most appropriate response? Perform mechanical débridement to remove the exudate and prevent further infection. Inform the primary care provider promptly because the graft may need to be removed. Perform range-of-motion exercises to increase perfusion to the graft site and facilitate healing. Document this finding as an expected phase of graft healing.

Inform the primary care provider promptly because the graft may need to be removed.

A client is admitted to the neurologic ICU with a spinal cord injury. In writing the client's care plan, the nurse specifies that contractures can best be prevented by what action? Repositioning the client every 2 hours Initiating range-of-motion exercises (ROM) as soon as the client initiates Initiating (ROM) exercises as soon as possible after the injury Performing ROM exercises once a day

Initiating (ROM) exercises as soon as possible after the injury

Which nursing intervention is required to prepare a client with cardiac dysrhythmia for an elective electrical cardioversion? Instruct the client to restrict food and oral intake Administer digitalis and diuretics 24 hours before cardioversion Facilitate CPR until the client is prepared for cardioversion Monitor blood pressure every 4 hours

Instruct the client to restrict food and oral intake

Which of the following tests or diagnostic tools is most applicable when considering heart failure interventions?

Invasive Hemodynamic Monitoring Invasive hemodynamic monitoring is used to directly measure pressures in the heart and great vessels and provides valuable information regarding vascular capacity, blood volume, pump effectiveness, and tissue perfusion

Which nursing intervention must a nurse perform when administering prescribed vasopressors to a client with a cardiac dysrhythmia? Keep the client flat for one hour after administration Administer every five minutes during cardiac resuscitation Document heart rate before and after administration Monitor vital signs and cardiac rhythm

Monitor vital signs and cardiac rhythm

Which nursing intervention can prevent a client from experiencing autonomic dysreflexia? Administering zolpidem tartrate (Ambien) Assessing laboratory test results as ordered Placing the client in Trendelenburg's position Monitoring the patency of an indwelling urinary catheter

Monitoring the patency of an indwelling urinary catheter

Regarding ECG interpretation, which of the following best describes the QRS complex on a normal ECG?

Normal QRS (< 0.12 seconds)

Nutrition in burns

Nutrition is vital because the client will need 4000 calories or more, and around 190 grams of protein/day (based on client weight). Supplements of essential vitamins C, A, and zinc to help with healing are also provided. Clients are encouraged to eat, if no paralytic ileus is present after the emergent phase is completed in 48 to 72 hours, and supplemented with enteral feeding

client with an ICD calls his cardiologist's office and talks to the nurse. He is concerned because he feels he is being defibrillated too often. The nurse tells the client to come to the office to be evaluated because the nurse knows that the most frequent complication of ICD therapy is what? Infection Failure to capture Premature battery depletion Oversensing of dysrhythmias

Oversensing of dysrhythmias

Which of the following interventions improves gas echange for patients with heart failure?

Oxygen

Regarding ECG interpretation, which of the following represents atrial depolarization?

P waves

Regarding ECG interpretation, which of the following best describes the criteria for a normal PR interval on a normal ECG?

PR Interval (< 0.20 seconds)

Which of the following is most likely indicated as an intervention in patients with severe heart failure?

Pacemaker For serious heart failure, an implanted device such as a pacemaker may be indicated to help the heart's chambers pump.

At the scene of a fire, the first priority is to prevent further injury. What are interventions at the site that can help to prevent injury? Select all that apply. Place the client in a horizontal position. Roll the client in a blanket to smother the fire. Place the client in a vertical position. Open a door and encourage air in an enclosed space.

Place the client in a horizontal position. Roll the client in a blanket to smother the fire.

The nurse is caring for an adult client whom the nurse suspects has digoxin toxicity. In addition to physical assessment, the nurse should collect what assessment information? Skin turgor Potassium level White blood cell count Peripheral pulses

Potassium level

The staff educator is precepting a nurse new to the critical care unit when a client with a T2 spinal cord injury is admitted. The client is soon exhibiting manifestations of neurogenic shock. In addition to monitoring the client closely, what would be the nurse's most appropriate action? Prepare to transfuse packed red blood cells. Prepare for interventions to increase the client's BP. Place the client in the Trendelenburg position. Prepare an ice bath to lower core body temperature.

Prepare for interventions to increase the client's BP.

Which ECG waveform characterizes conduction of an electrical impulse through the left ventricle? P wave QRS complex PR interval QT interval

QRS complex

Autonomic dysreflexia is an acute emergency that occurs with spinal cord injury as a result of exaggerated autonomic responses to stimuli. Which of the following is the initial nursing intervention to treat this condition? Examine the skin for any area of pressure or irritation. Examine the rectum for a fecal mass. Empty the bladder immediately. Raise the head of the bed and place the patient in a sitting position.

Raise the head of the bed and place the patient in a sitting position

A client has been diagnosed with heart failure. What is the major nursing outcome for the client? Reduce the workload on the heart. Walk 30 minutes three times a week. Maintain a healthy diet. Sleep 8 hours per night.

Reduce the workload on the heart.

The nurse recognizes which symptom as a classic sign of cardiogenic shock? Restlessness and confusion Hyperactive bowel sounds High blood pressure Increased urinary output

Restlessness and confusion

Why does a client with left-sided heart failure require careful monitoring? Right-sided heart failure is a risk. Depression is likely. Accelerated weight loss is probable. The client is more likely to develop migraines.

Right-sided heart failure is a risk.

Which intervention helps to minimize the risk of further injury to an affected person at the scene of a fire? Roll the client in a blanket Cover the client with a wet cloth Place the client with the head positioned slightly below the rest of the body Avoid immediate IV fluid therapy

Roll the client in a blanket

The nurse overseeing care in the ICU reviews the shift report on four clients. The nurse recognizes which client to be at greatest risk for the development of cardiogenic shock? The client admitted with acute renal failure The client admitted following an MI The client admitted with malignant hypertension The client admitted following a stroke

The client admitted following an MI

A nurse on the neurologic unit is providing care for a client who has spinal cord injury at the level of C4. When planning the client's care, what aspect of the client's neurologic and functional status should the nurse consider? The client will be unable to use a wheelchair. The client will be unable to swallow food. The client will be continent of urine, but incontinent of bowel. The client will require full assistance for all aspects of elimination.

The client will require full assistance for all aspects of elimination.

Which of the following best describes the pathophysiology of high output heart failure?

Unable to Meet Metabolic Needs A variety of conditions can significantly increase the body's need for blood and oxygen, resulting in high output heart failure, but the end result is the heart being unable to meet the body's metabolic needs.

Regarding ECG interpretation, which of the following best describes the morphology of P waves on a normal ECG?

Upright, Rounded, Before Every QRS

A client who is being treated in the hospital for a spinal cord injury is advocating for the removal of his urinary catheter, stating that he wants to try to resume normal elimination. What principle should guide the care team's decision regarding this intervention? Urinary catheters often lead to urinary tract infections. Urinary function is permanently lost following an SCI. Urinary catheters should not remain in place for more than 7 days. Overuse of urinary catheters can exacerbate nerve damage.

Urinary catheters often lead to urinary tract infections.

The school nurse is giving a presentation on preventing spinal cord injuries (SCI). What should the nurse identify as prominent risk factors for SCI? Select all that apply. Young age Frequent travel African American race Male gender Alcohol or drug use

Young age Male gender Alcohol or drug use

The nurse is caring for a client with heart failure. What sign will lead the nurse to suspect right-sided heart failure? warm extremities ascites resting bradycardia weight loss

ascites

Surgery 1. Cervical discectomy / laminectomy: Nursing interventions a. Routine post-op care 5

b. Position: Head elevated 20-30 degrees c. Turn every 2 hours using log-rollingtechnique d. Assess: 1) Vital signs 2) Airway 3) Upper extremity neuro checks

Lumbar discectomy / laminectomy: Nursing interventions a. Routine post-op care 5

b. Position: flat - usually supine c. Turn every 2 hours using log-rollingtechnique d. Assess: 1) Vital signs 2) Bowel and bladder function 3) Lower extremity neuro checks

A client asks the nurse if systolic heart failure will affect any other body function. What body system response correlates with systolic heart failure (HF)? decrease in renal perfusion increased blood volume ejected from ventricle vasodilation of skin dehydration

decrease in renal perfusion

Epinephrine s/e

increases BP and HR -tachycardia and severe HTN

A client is admitted to the neurologic ICU with a C4 spinal cord injury. When writing the plan of care for this client, which of the following nursing diagnoses would the nurse prioritize in the immediate care of this client? Risk for impaired skin integrity related to immobility and sensory loss Impaired physical mobility related to loss of motor function Ineffective breathing patterns related to weakness of the intercostal muscles Urinary retention related to inability to void spontaneously

ineffective breathing patterns related to weakness of the intercostal muscles

n which of the following Types of Heart Failure is pulmonary congestion most likely to be seen?

left sided

A client has been admitted to the cardiac step-down unit with acute pulmonary edema. Which symptoms would the nurse expect to find during assessment? moist, gurgling respirations drowsiness, numbness increased cardiac output hypertension

moist, gurgling respirations

A client's electrocardiogram reveals an irregular rhythm of 75 bpm with a normal QRS and P wave. The nurse who is caring for the client should anticipate: administration of epinephrine. a bolus of warmed normal saline. administration of a beta-adrenergic blocker. no immediate treatment.

no immediate treatment.

When the client has increased difficulty breathing when lying flat, the nurse records that the client is demonstrating orthopnea. dyspnea upon exertion. hyperpnea. paroxysmal nocturnal dyspnea.

orthopnea.

During your assessment of a patient with right-sided heart failure, which of the following is most likely to be seen?

peripheral edema

A client with a burn wound is prescribed mafenide acetate 5% twice daily. Nursing implications associated with this medication include monitoring the client for the development of respiratory acidosis. premedicating the client with an analgesic prior to application. monitoring the client's Na+ and K+ serum levels and replace as prescribed. protecting the bed linens and client's clothing from contact to prevent staining.

premedicating the client with an analgesic prior to application.

Regarding ECG interpretation, which of the following is assessed by counting the number of QRS complexes over a 6-second interval and multiplying by 10?

rate

Regarding ECG interpretation, which of the following is assessed by measuring the consistency of duration between each R-R interval?

rhythm

A client was burned in a home accident. The ED physician indicated the client's wound, with proper care, should heal within 2 weeks. How was this client's wound classified? second degree first degree third degree fourth degree

second degree

The nurse is caring for a client immediately following a spinal cord injury (SCI). Which is an acute complication of SCI? Cardiogenic shock Tetraplegia Spinal shock Paraplegia

spinal shock

Dopamine is used for

treat the symptoms of low blood pressure, low cardiac output and improves blood flow to the kidneys. and to treat shock; increases contractility

Nitroglycerin- Most common side effects

vasodilates(widens) the arteries, thus reducing cardiac workload and blood pressure -hypotension (with that comes orthostatic hypotension so tell the client to change positions slowly, etc.

S/S cervical spine of herniated disc 6

• Headache • Arm pain • Parathesis • Numbness in arms • Radicular pain • Neck pain • Positional pain

S/S lumbar spine of herniated disc 8

• Lower back pain • Leg pain • Foot pain • Muscle weakness • Spasms • Overactive reflexes • Leg numbness, pins & needles or uncomfortable tingling and burning. • Foot drop • Postural changes • Urinary dysfunction • Male sexual dysfunction • Absent cord reflexes

Neurogenic shock 5

• Medical emergency • Ussually happens with injuries above t6 • s/s • Massive vasodialation • Decrease perfusion to organs • Hypotension and bradcardia

Spinal shock s/s 5

• Not a medical emergency • S/s: • Decrease reflexes • Motor loss • Sensory loss • Hypotension; bradycardia • Can last days to months

S/S thoracic spine of herniated disc 4

• Pain that affects the trunk and diaphragm • Radiating chest pain • If spinal cord compression in the T spine it may affect both legs. -Changes in bladder and bowel habits