Ch. 40

The nurse is administering mouth care to an unconscious client. The nurse should perform which actions in the care of this person? Select all that apply. 1. Position the client on his or her side. 2. Use products that contain alcohol. 3. Brush the teeth with a small, soft toothbrush. 4. Cleanse the mucous membranes with soft sponges. 5. Use lemon glycerin swabs when performing mouth care.

1,3,4 Rationale: The unconscious client is positioned on the side during mouth care to prevent aspiration. The teeth are brushed at least twice daily with a small toothbrush. The gums, tongue, roof of the mouth, and oral mucous membranes are cleansed with soft sponges to avoid encrustation and infection. The lips are coated with water-soluble lubricant to prevent drying, cracking, and encrustation. The use of products with alcohol should be avoided because they have a drying effect.

The nurse is developing a teaching plan for a client with a history of low back pain. Which instructions does the nurse plan to include in teaching the client about preventing low back pain and injury? (Select all that apply.) "Do not wear high-heeled shoes." "Keep weight within 50% of ideal body weight." "Begin a regular exercise program to strengthen your back." "When lifting something, the back should be straight and the knees bent." "Standing for long periods of time will help to prevent low back pain."

"Do not wear high-heeled shoes." "Begin a regular exercise program to strengthen your back." "When lifting something, the back should be straight and the knees bent." The nurse includes the following instructions into the low back pain client's teaching plan: don't wear high-heeled shoes, begin a regular exercise program, and keep the back straight and knees bent when lifting something. Wearing high-heeled shoes can increase back strain. Beginning a regular exercise program will help to promote back strengthening. Keeping the back straight while bending the knees is the proper way to lift objects and will help to prevent back injury.The client needs to avoid standing or sitting for long periods of time because this can cause further strain on the back. Weight needs to be kept within 10% of ideal body weight and not 50%.

A client with a T6 spinal cord injury who is on the rehabilitation unit suddenly develops facial flushing and reports a severe headache. Blood pressure is elevated, and the heart rate is slow. Which action does the nurse take first? Check for fecal impaction. Help the client sit up. Insert a straight catheter. Loosen the client's clothing.

Help the client sit up. The nurse's first action for a T6 spinal cord injury client suddenly developing facial flushing and severe headache is to help the client sit up. The client is experiencing autonomic dysreflexia, which can produce severe and rapidly occurring hypertension. Getting the client to sit upright is the easiest and quickest action to take and has the most immediate chance of lowering blood pressure to the brain.Checking for fecal impaction, inserting a straight catheter, and loosening the clothing are important but will not immediately reduce blood pressure.

A client with a spinal cord injury is prone to experiencing autonomic dysreflexia. The nurse should include which measures in the plan of care to minimize the risk of occurrence? Select all that apply. Keeping the linens wrinkle-free under the client Preventing unnecessary pressure on the lower limbs Limiting bladder catheterization to once every 12 hours Turning and repositioning the client at least every 2 hours Ensuring that the client has a bowel movement at least once a week

Keeping the linens wrinkle-free under the client Preventing unnecessary pressure on the lower limbs Turning and repositioning the client at least every 2 hours Rationale: The most frequent cause of autonomic dysreflexia is a distended bladder. Straight catheterization should be done every 4 to 6 hours (catheterization every 12 hours is too infrequent), and urinary catheters should be checked frequently to prevent kinks in the tubing. Constipation and fecal impaction are other causes, so maintaining bowel regularity is important. Ensuring a bowel movement once a week is much too infrequent. Other causes include stimulation of the skin from tactile, thermal, or painful stimuli. The nurse administers care to minimize risk in these areas.

A 19-year-old man who was involved in a motor vehicle accident is brought to the ED. The patient was stopped at a red light when he was hit from behind by another vehicle traveling at 15 mph. The patient was placed in a cervical immobilizer by the paramedics. He is alert and oriented, states that his neck hurts, and is in no apparent distress. He currently rates his neck pain as a "5" on a 0-to-10 scale. Which assessment will the nurse perform first? Airway Circulation Sensory-motor Level of consciousness

ANS: A Even if the patient is in no apparent distress, airway must always be assessed first. Circulation, level of consciousness, and the sensory-motor system can be assessed after the airway.

A nurse assesses a client who is recovering from an open anterior cervical discectomy and fusion. Which complication would alert the nurse to urgently communicate with the primary health care provider? a. Auscultated stridor b. Weak pedal pulses c. Difficulty swallowing d. Inability to shrug shoulders

ANS: A Postoperative swelling can narrow the trachea, cause a partial airway obstruction, and manifest as stridor. The client may also have trouble swallowing, but maintaining an airway takes priority. Weak pedal pulses and an inability to shrug the shoulders are not complications of this surgery.

The nurse is taking a history on an older adult. Which factors would the nurse assess as potential risks for low back pain? (Select all that apply.) a. Scoliosis b. Spinal stenosis c. Hypocalcemia d. Osteoporosis e. Osteoarthritis

ANS: A, B, C, D, E All of these factors place the client at risk for low back pain due to changes in spinal alignment, loss of bone, or joint degeneration. Bone loss worsens if serum calcium levels are below normal.

A nurse assesses a client who experienced a spinal cord injury at the T5 level 12 hours ago. Which assessment findings would the nurse correlate with neurogenic shock? (Select all that apply.) a. Heart rate of 34 beats/min b. Blood pressure of 185/65 mm Hg c. Urine output less than 30 mL/hr d. Decreased level of consciousness e. Increased oxygen saturation

ANS: A, C, D Neurogenic shock with acute spinal cord injury manifests with decreased oxygen saturation, symptomatic bradycardia, decreased level of consciousness, decreased urine output, and hypotension.

A nurse assesses a client who recently experienced a traumatic spinal cord injury. Which assessment data would the nurse obtain to assess the client's coping strategies? (Select all that apply.) a. Spiritual beliefs b. Level of pain c. Family support d. Level of independence e. Annual income f. Previous coping strategies

ANS: A, C, D, F Information about the client's preinjury psychosocial status, usual methods of coping with illness, difficult situations, and disappointments would be obtained. Determine the client's level of independence or dependence and his or her comfort level in discussing feelings and emotions with family members or close friends. Clients who are emotionally secure and have a positive self-image, a supportive family, and financial and job security often adapt to their injury. Information about the client's spiritual and religious beliefs or cultural background also assists the nurse in developing the plan of care. The other options do not supply as much information about coping.

A nurse promotes the prevention of lower back pain by teaching clients at a community center. Which statement(s) would the nurse include in this education? (Select all that apply.) a. "Participate in an exercise program to strengthen back muscles." b. "Purchase a mattress that allows you to adjust the firmness." c. "Wear flat instead of high-heeled shoes to work each day." d. "Keep your weight within 20% of your ideal body weight." e. "Avoid prolonged standing or sitting, including driving."

ANS: A, C, E Exercise can strengthen back muscles, reducing the incidence of low back pain. Women should avoid wearing high-heeled shoes because they cause misalignment of the back. Prolonged standing and sitting should also be avoided. The other options will not prevent low back pain.

A nurse assesses cerebrospinal fluid leaking onto a client's surgical dressing. What actions would the nurse take? (Select all that apply.) a. Place the client in a flat position. b. Monitor vital signs for hypotension. c. Utilize a bedside commode. d. Assess for abdominal distension. e. Report the leak to the surgeon.

ANS: A, E If cerebrospinal fluid (CSF) is leaking from a surgical wound, the nurse would place the client in a flat position and contact the surgeon for repair of the leak. Hypotension and abdominal distension are not complications of CSF leakage.

A client who had a complete spinal cord injury at level L5-S1 is admitted with a sacral pressure injury. What other assessment finding will the nurse anticipate for this client? a. Quadriplegia b. Flaccid bowel c. Spastic bladder d. Tetraparesis

ANS: B A low-level complete spinal cord injury (SCI) is a lower motor neuron injury because the reflect arc is damaged. Therefore, the client would be expected to have paraplegia and a flaccid bowel and bladder. Quadriplegia and tetraparesis are seen in clients with cervical or high thoracic SCIs.

A nurse teaches a client who is recovering from an open traditional cervical spinal fusion. Which statement would the nurse include in this client's postoperative instructions? a. "Only lift items that are 10 lb (4.5 kg) or less." b. "Wear your neck brace whenever you are out of bed." c. "You must remain in bed for 3 weeks after surgery." d. "You will be prescribed medications to prevent graft rejection."

ANS: B Clients who undergo spinal fusion are fitted with a neck brace that they must wear throughout the healing process whenever they are out of bed. The client should not lift anything more than 10 lb (4.5 kg). The client does not need to remain in bed. Medications for rejection prevention are not necessary for this procedure.

A nurse assesses a client with multiple sclerosis after administering prescribed fingolimod. For which common side effect would the nurse monitor? a. Peripheral edema b. Facial flushing c. Tachycardia d. Fever

ANS: B Fingolimod is an oral immunomodulator that has two common side effects—facial flushing and GI disturbance, such as diarrhea. Peripheral edema, tachycardia, and fever are not common side effects of this drug.

A nurse cares for a client with a spinal cord injury. With which interprofessional health team member would the nurse collaborate to assist the client with activities of daily living? a. Social worker b. Physical therapist c. Occupational therapist d. Case manager

ANS: C The occupational therapist instructs the patient in the correct use of all adaptive equipment. In collaboration with the therapist, the nurse instructs family members or the caregiver about transfer skills, feeding, bathing, dressing, positioning, and skin care. The other team members are consulted to assist the client with other issues.

The nurse is preparing to teach a client recently diagnosed with multiple sclerosis about taking glatiramer acetate. Which statement by the client indicates a need for further teaching? a. "I will rotate injection sites to prevent skin irritation." b. "I need to avoid large crowds and people with infection." c. "I should report any flulike symptoms to my primary health care provider." d. "I will report any signs of infection to my primary health care provider."

ANS: C Glatiramer is given by subcutaneous injection. The first dose is administered under medical supervision, but the nurse teaches the client how to self-administer the medication after the initial dose, reminding the client about the need to rotate injection sites. Like other immunomodulators, this drug can make the client susceptible to infection. However, flulike symptoms occur more commonly with interferons rather than glatiramer.

In assessing a patient with low back pain, which priority assessment question or statement will the nurse provide? "How long have you had back pain?" "How does your back pain affect your activities of daily living?" "Tell me about your pain and what interventions are helpful in managing your pain." "Have you ever had magnetic resonance imaging to find a cause for your back pain?"

ANS: C Obtaining a thorough assessment of the patient's pain level and effective interventions to treat pain is an important element of the nursing assessment. The priority assessment question helps the nurse more fully understand the patient's experience with pain, and how the patient has attempted to address the pain. All other questions can be asked as follow-ups to the priority question.

A nurse assesses a client with a spinal cord injury at level T5. The client's blood pressure is 184/95 mm Hg, and the client presents with a flushed face and blurred vision. After raising the head of the bed, what action would the nurse take next? a. Initiate oxygen via a nasal cannula. b. Recheck the client's blood pressure. c. Palpate the bladder for distention. d. Administer a prescribed beta blocker.

ANS: C The client is manifesting symptoms of autonomic dysreflexia. Common causes include bladder distention, tight clothing, increased room temperature, and fecal impaction. If persistent, the client could experience neurologic injury such as s stroke. The other actions are not appropriate for this complication.

A nurse assesses a client who is recovering from an open traditional lumbar laminectomy with fusion. Which complications would the nurse report to the primary health care provider? (Select all that apply.) a. Surgical discomfort b. Redness and itching at the incision site c. Incisional bulging d. Clear drainage on the dressing e. Sudden and severe headache

ANS: C, D, E Bulging at the incision site or clear fluid on the dressing after open back surgery strongly suggests a cerebrospinal fluid leak, which constitutes an emergency. Loss of cerebrospinal fluid may cause a sudden and severe headache. Pain, redness, and itching at the site are normal.

After teaching a male client with a spinal cord injury at the T4 level, the nurse assesses the his understanding. Which client statements indicate a correct understanding of the teaching related to sexual effects of his injury? (Select all that apply.) a. "I will explore other ways besides intercourse to please my partner." b. "I will not be able to have an erection because of my injury." c. "Ejaculation may not be as predictable as before." d. "I may urinate with ejaculation but this will not cause infection." e. "I should be able to have an erection with stimulation."

ANS: C, D, E Men with injuries above T6 often are able to have erections by stimulating reflex activity. For example, stroking the penis will cause an erection. Ejaculation is less predictable and may be mixed with urine. However, urine is sterile, so the client's partner will not get an infection.

A patient with a spinal cord injury at C5-C6 reports a sudden severe headache. The patient is flushed. Vital signs include a blood pressure of 190/100 mm Hg and heart rate of 52 beats/min. What is the priority nursing intervention? Notify the health care provider. Place the patient in a sitting position. Check the patient for fecal impaction. Check the urinary catheter for kinks or obstruction.

ANS: Place the patient in a sitting position. Autonomic dysreflexia is an excessive, uncontrolled sympathetic output and is a neurologic emergency in patients with spinal cord injury T6 and above. The first priority of care is to place the patient in a sitting position. Then contact the health care provider to treat the increased blood pressure. The cause of this syndrome is a noxious stimulus—most often a distended bladder or constipation. Rapid treatment is essential to prevent a stroke.

The nurse understand which of the following is a risk factor associated with the development of multiple sclerosis? Smoking High-fat diet Age greater than 70 Gender

ANS: D MS affects women two to three times more often than men, suggesting a possible hormonal role in disease development. Some studies show that the disease occurs up to four times more often in women than men (National Multiple Sclerosis Society, 2016).

The nurse initiates care for a client with a cervical spinal cord injury who arrives via emergency medical services. What action would the nurse take first? a. Assess level of consciousness. b. Obtain vital signs. c. Administer oxygen therapy. d. Evaluate respiratory status.

ANS: D The first priority for a client with a spinal cord injury is assessment of respiratory status and airway patency. Clients with cervical spine injuries are particularly prone to respiratory compromise due to interference with diaphragmatic innervation. The other actions would be performed after airway and breathing are assessed.

A nurse is caring for a client who has a halo fixator device with vest for a complete cervical spinal cord injury. Which assessment finding will the nurse report to the primary health care provider? A. Purulent drainage from the pin sites on the client's forehead B. Painful pressure injury under the collar C. Inability to move legs or feet D. Oxygen saturation of 95% on room air

Answer: A Rationales: The client wearing a halo device for a complete spinal cord injury cannot move his or her legs of feet which makes Choice C an incorrect response. An oxygen saturation of 95% on room air is normal and does not require a report to the primary health care provider. Choice B is incorrect because a halo device is not the same as a hard cervical collar. Instead, Choice A is correct because the halo is put in place with four pins into the skull which can become infected. This change needs to be reported to the primary health care provider.

A client is admitted with a suspected cervical spinal cord injury. What is the nurse's priority action for this client? A. Assess cardiac sounds. B. Manage the client's airway. C. Check oxygen saturation level. D. Perform a neurologic assessment.

Answer: B Rationale: Although all of these actions are appropriate, Choice B is the priority because the client needs a patent airway as the first desired outcome.

A client who sustained a recent cervical spinal cord injury reports having a throbbing headache and feeling flushed. The client's blood pressure is 190/110. What is the nurse's priority action at this time? A. Perform a bladder assessment. B. Insert an indwelling urinary catheter. C. Place the patient in a sitting position. D. Turn on a fan to cool the patient.

Answer: C Rationales: The patient's high blood pressure (BP) is causing the headache and flushing. If the BP continues to remain elevated, the patient is at risk for stroke. Therefore, sitting the patient up will help to lower the blood pressure and is the first priority action for the nurse. The other choices would be the next actions to determine and relieve the cause of the autonomic dysreflexia.

The nurse is teaching a client starting on fingolimod to treat multiple sclerosis about the drug's possible side and adverse effects. Which effects will the nurse include in the teaching? (Select all that apply.) Tachycardia Facial flushing Infection Nausea/vomiting Diarrhea Hypertension

Facial flushing Infection Nausea/vomiting Diarrhea The nurse teaches the client and family to monitor the client's pulse because fingolimod causes bradycardia rather than tachycardia. Most oral immunomodulating drugs cause facial flushing, GI disturbances, and decreased white blood cell count that can cause the client to be at risk for infection.

Which nursing intervention is best for preventing complications of immobility when caring for a client with spinal cord injury? Encouraging nutrition Frequent ambulation Regular turning and repositioning Special pressure-relief devices

Regular turning and repositioning Regular turning and repositioning are the best way to prevent complications of immobility in clients with spinal cord problems.A registered dietitian may be consulted to encourage nutrition to optimize diet for general health and to reduce osteoporosis. Frequent ambulation may not be possible for these clients. Use of special pressure-relief devices is important but is not the best way to prevent immobility complications.

The nurse is caring for a client who sustained a complete cervical spinal cord injury and is at risk for autonomic dysreflexia. Which assessment findings would the nurse anticipate if this complication occurs? (Select all that apply.) Sudden and severe hypertension Profuse sweating above the injury level Goose bumps above and/or below the injury level Nasal congestion and blurred vision Severe throbbing headache Facial and skin flushing

Sudden and severe hypertension Profuse sweating above the injury level Goose bumps above and/or below the injury level Nasal congestion and blurred vision Severe throbbing headache Facial and skin flushing All of these findings commonly occur in clients who experience autonomic dysreflexia.

Ten days later the patient is to be discharged to a rehabilitation facility. The nurse understand which to be realistic initial priorities of care during rehabilitation? (Select all that apply.) Teaching self-care skills Working on mobility skills Bowel and bladder retraining Returning to pre-injury status Training caregivers to take over patient's care

Teaching self-care skills Working on mobility skills Bowel and bladder retraining During rehabilitation, patients learn about self-care, mobility skills, and work on bowel and bladder retraining. A typical stay is 1 to 2 months. A return to pre-injury status may not be a realistic goal. Although caregivers may need training at a later time, this is not the priority of initial rehabilitative care.

The nurse is collaborating with the rehabilitation therapist to improve mobility skills for a client with a complete high-level spinal cord injury. Which technique is appropriate for this client? Use of a mechanical lift to get the client out of bed Use of parallel bars to facilitate ambulation Use of a sliding board (slider) to transfer from bed to a chair Use of a walker to promote balance and prevent muscle atrophy

Use of a sliding board (slider) to transfer from bed to a chair The client who has a complete high-level, or cervical, spinal cord injury is tetraplegic (quadriplegic) meaning that he or she does not have control over any extremity. The client has shoulder movement allowing the client to use a sliding board as a "bridge" between the bed and chair.