Evolve Chapter 43
"It's important I work out in the afternoon so my muscles are warmed up." More teaching is needed for the client with PPMS when the client says, "It's important I work out in the afternoon so my muscles are warmed up." Working out in the afternoon will increase body temperature and lead to fatigue. Fatigue is a key feature of MS. Working with a physical therapist to develop an appropriate exercise program tailored to the client's condition will be beneficial.If a client has diplopia, wearing an eye patch and alternating it between eyes every few hours may relieve the symptoms. Keeping the home organized and clutter free will decrease the risk of falls. Keeping medications and other important belongings in the same place and maintaining a routine may help with memory deficits that may occur with MS.
A client has been diagnosed with Primary Progressive MS (PPMS) and the nurse is providing education at the clinic. What statement by the client indicates the need for more teaching? "I can alternate wearing my eye patch between eyes for double vision." "I should keep my home clutter free so I don't fall." "It's important I work out in the afternoon so my muscles are warmed up." "I always keep my medications in the same place."
"I can go home the day of the procedure." The statement that indicates the client correctly understands preoperative teaching of a microdiskectomy is "I can go home the day of the procedure." A microdiskectomy is considered minimally invasive surgery (MIS) and does not typically require an inclient hospital stay.The client who undergoes a minimally invasive surgery does not have to wait 48 hours after the procedure to return home, will not have a drain in place after the procedure, and will not need to wear special stockings after the procedure. These steps are used in the case of traditional open laminectomy, not MIS.
A client has received preoperative teaching from the nurse for a microdiskectomy. Which statement by the client indicates a correct understanding of the nurse's instruction? "I can go home the day of the procedure." "I can go home 48 hours after the procedure." "I'll have a drain in place after the procedure." "I'll need to wear special stockings after the procedure."
Positioning the client to maximize ventilation potential The priority nursing intervention for a client with a spinal cord injury at the seventh cervical vertebra is to position the client to maximize ventilation potential. Airway management is the priority for the client with a spinal cord injury. The client with a cervical spinal cord injury is at high risk for respiratory compromise because the cervical spinal nerves (C3-C5) innervate the phrenic nerve, controlling the diaphragm.Auscultating bowel sounds is important since paralytic ileus can develop from a SCI; however this is not the priority intervention. Beginning bladder retraining and monitoring the nutritional status will be important for adequate healing and progress to rehabilitation. However, these interventions can be delayed until major life threats are addressed.
A client is admitted with a spinal cord injury at the seventh cervical vertebra secondary to a gunshot wound. Which nursing intervention is the priority for this client's care? Auscultating bowel sounds every 2 hours Beginning a bladder retraining program Monitoring nutritional status Positioning the client to maximize ventilation potential
National Spinal Cord Injury Association The best resource for the nurse to provide is the National Spinal Cord Injury Association. The National Spinal Cord Injury Association will inform the client of support groups in the area and will assist in answering questions regarding adjustment in the home setting.The hospital library is not typically consumer-oriented. Most information available in the library is targeted to health care professionals. The Internet is not the best resource simply because of the unlimited volume of information available and its questionable quality. Although the provider's office may have information, the information may not be as comprehensive and current as other options.
A client is being discharged with paraplegia secondary to a motor vehicle crash and expresses concern over the ability to cope in the home setting after the injury. Which is the best resource for the nurse to provide for the client? Hospital library Internet National Spinal Cord Injury Association Provider's office
Fat embolism syndrome The nurse is concerned that fat embolism syndrome has occurred. Fat embolism syndrome (FES) is characterized by chest pain, dyspnea, anxiety, and mental status changes. Petechiae may develop around the neck, over the upper chest, buccal mucosa, and conjunctiva. This is an emergency. The nurse must notify the primary health care provider immediately.Autonomic dysreflexia is not associated with lumbar laminectomies. It is seen in spinal cord injuries. A cerebrospinal fluid (CSF) leak is a concern with laminectomy but would not present with these symptoms. Paralytic ileus may occur but is associated with abdominal pain and distention.
A client on the neurosurgical floor who had a lumbar laminectomy is confused, agitated, and complaining of difficulty breathing. The client is normally alert and oriented. The nurse notices a pinpoint rash over the client's chest. What condition is the nurse concerned has occurred? Autonomic dysreflexia CSF leak Fat embolism syndrome Paralytic ileus
Assess airway and breathing. The nurse's first action when a client returns to the neurosurgical floor after having an anterior cervical discectomy is to assess the airway and breathing. Assessment in the immediate postoperative period after an ACDF is maintaining an airway and ensuring that the client has no problem with breathing.Administration of pain medication, ambulation, and assessing the client's ability to void are important but are not the highest priority.
A client returns to the neurosurgical floor after undergoing an anterior cervical diskectomy and fusion (ACDF). What is the nurse's first action? Administer pain medication. Assess airway and breathing. Assist with ambulation. Check the client's ability to void.
Nifedipine (Procardia) The nurse anticipates that the primary health care provider will prescribe nifedipine for a spinal cord injury client who has an elevated blood pressure and severe headache. This client is experiencing autonomic dysreflexia (AD). Nifedipine (Procardia), a calcium channel blocker, can be administered to treat AD and lower blood pressure. If AD is not treated, a hemorrhagic stroke can occur.Dopamine hydrochloride (Inotropin) is an inotropic agent used to treat severe hypotension. Methylprednisolone (Solu-Medrol) is a glucocorticoid and is not indicated because it may further increase blood pressure. Ziconotide (Prialt) is an N-type calcium channel blocker on those nerves that usually transmit pain signals to the brain.
A client who has just undergone spinal surgery must be moved. How does the nurse plan to move this client? Getting the client up in a chair Keeping the client in the Trendelenburg position Lifting the client in unison with other health care personnel Log rolling the client
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 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.
Drowsiness Adverse effects of tizanidine include drowsiness and sedation. Tizanidine (Zanaflex, Sirdalud) is a centrally acting skeletal muscle relaxant.It does not cause hirsutism, hypertension, or tachycardia.
A client with severe muscle spasticity has been prescribed tizanidine (Zanaflex, Sirdalud). The nurse instructs the client about which adverse effect of tizanidine? Drowsiness Hirsutism Hypertension Tachycardia
"Please request a meeting with the health care provider. I will help set that up." The nurse's best response to a family member of a client with a recent spinal cord injury is, "Please request a meeting with the primary health care provider. I will set that up." Questions concerning prognosis and potential for recovery would be referred to the primary health care provider. The nurse can help facilitate the meeting however.The timing and extent of recovery are different for each client, but it is not the nurse's role to inform the client and family members of the client's prognosis. Telling the family that "only time will tell" is too vague and minimizes the family's concern. The client was informed of Health Insurance Portability and Accountability Act (HIPAA) rights on admission or when consciousness was established, so permission has already been granted by the client.
A family member of a client with a recent spinal cord injury asks the nurse, "Can you please tell me what the real prognosis for recovery is? I don't feel like I'm getting a straight answer." What is the nurse's best response? "Every injury is different, and it is too soon to have any real answers right now." "Only time will tell." "The Health Insurance Portability and Accountability Act requires that I obtain the client's permission first." "Please request a meeting with the health care provider. I will help set that up."
Sensation The nurse uses a paper clip bilaterally on each limb of the client with back pain to assess sensation. Both extremities may be checked for sensation by using a paper clip and a cotton ball for comparison of light and deep touch. The client may feel sensation in both limbs but may experience a stronger sensation on the unaffected side.Gait is assessed by having the client walk. Mobility is assessed by determining the client's ability to move on his/her own, turn or perform ADLs. Strength is measured by having the client perform bilateral grips.
In assessing a client with back pain, the nurse uses a paper clip bilaterally on each limb. What is the nurse assessing? Gait Mobility Sensation Strength
Patent airway The nursing priority when assessing a client with a spinal cord injury is a patent airway. Clients with injuries at or above T6 are at risk for respiratory complications. Assessing for a patent airway is essential.Asking the client about current medications and allergies is part of every trauma assessment. Assessing the level of consciousness utilizing the Glasgow Coma Score (GCS) is an important part of the trauma assessment. Determining the level of loss of sensation will be included in the neurological evaluation.
In the emergency department (ED), which is the nursing priority in assessing the client with a spinal cord injury? Indication of allergies Level of consciousness Loss of sensation Patent airway
The client's chest moves very little with each respiration. The most rapid action is needed for a spinal cord injury client injured one hour prior to arrival whose chest moves very little with each respiration. Airway and breathing are always of major concern in a spinal cord injury, especially in an injury near C3 to C5, where the spinal nerves control the diaphragm.Bradycardia and hypotension are indications neurogenic shock due to disruption of autonomic pathways. This will need to be addressed rapidly however airway and breathing are always the top priority. Flaccid paralysis below the level of the injury is to be expected.
The nurse is caring for a client in the emergency department (ED) whose spinal cord was injured at the level of C7 1 hour prior to arrival. Which assessment finding requires the most rapid action? After two fluid boluses, the client's systolic blood pressure remains 80 mm Hg. Cardiac monitor shows a sinus bradycardia at a rate of 50 beats/min. The client's chest moves very little with each respiration. The client demonstrates flaccid paralysis below the level of injury.
The client is reporting difficulty swallowing secretions. The nursing assessment finding that is the greatest concern for a postoperative anterior cervical diskectomy client is the client reporting difficulty swallowing secretions. This may indicate swelling in the neck and the potential for compromise of the client's airway.Experiencing neck pain and numbness and tingling bilaterally down the arms are expected findings after this surgery. Serosanguineous fluid oozing onto the neck dressing is also a normal finding after this surgery.
The nurse is caring for a client postoperatively after an anterior cervical diskectomy and fusion. Which assessment finding is of greatest concern to the nurse? Neck pain is at a level 7 on a 0-to-10 scale. Serosanguineous fluid oozes onto the neck dressing. The client is reporting difficulty swallowing secretions. The client has numbness and tingling bilaterally down the arms.
Log rolling the client Log rolling the client who has undergone spinal surgery is the best way to keep the spine in alignment. The client who has undergone spinal surgery must remain straight and turned as a unit.The Trendelenburg position is not indicated for the client who has undergone spinal surgery, nor should the client be lifted or encouraged to get up in a chair.
The nurse is caring for a client with a spinal cord injury resulting from a diving accident, who has a halo fixator and an indwelling urinary catheter in place. The nurse notes that the blood pressure is elevated and that the client is reporting a severe headache. The nurse anticipates that the primary health care provider will prescribe which medication? Dopamine hydrochloride (Inotropin) Methylprednisolone (Solu-Medrol) Nifedipine (Procardia) Ziconotide (Prialt)
"Do not wear high-heeled shoes." "Begin a regular exercise program." "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%.
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." "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."
"Keep straws available for drinking fluids." The instructions the nurse include for a client with a halo device is to keep straws available for drinking fluids. The halo device makes it difficult to bring a cup or a glass to the mouth.The head would be supported with a small pillow when sleeping to prevent unnecessary pressure and discomfort. Driving must be avoided because vision is impaired with the device. Swimming must be avoided to prevent the risk for infection.
The nurse is providing instructions to a client with a spinal cord injury about caring for the halo device. The nurse plans to include which instructions? "Avoid using a pillow under the head while sleeping." "Begin driving 1 week after discharge." "Keep straws available for drinking fluids." "Swimming is recommended to keep active."
"Parts of my nervous system have plaques." The statement that demonstrates that the newly diagnosed client with MS correctly understands the pathophysiology of the disease is "parts of my nervous system have plaques." MS is characterized by an inflammatory response that results in diffuse random or patchy areas of plaque in the white matter of the central nervous system.The client with MS has no decrease in life expectancy. Frequent times of remission are common in clients with MS. There is no known cause for MS.
The nurse is teaching a client newly diagnosed with multiple sclerosis (MS). Which statement by the client indicates a correct understanding of the pathophysiology of the disease? "I will die early." "I will have gradual deterioration with no healthy times." "Parts of my nervous system have plaques." "This was caused by getting too many x-rays as a child."
Respiratory therapy To help prevent death for a client with spinal cord injury, collaboration with the Respiratory therapy team is a priority. A client with a cervical spinal cord injury is at risk for breathing problems including pneumonia and aspiration, resulting from the interruption of spinal innervation to the respiratory muscles. Collaboration with Respiratory therapy is crucial.Collaboration with nutritional therapy, occupational therapy, and physical therapy does not help prevent the leading cause of death in clients with spinal cord injury.
To prevent the leading cause of death for clients with spinal cord injury, collaboration with which component of the primary health care team is a nursing priority? Nutritional therapy Occupational therapy Physical therapy Respiratory therapy
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.
Which nursing intervention is best for preventing complications of immobility when caring for a client with spinal cord problems? Encouraging nutrition Frequent ambulation Regular turning and repositioning Special pressure-relief devices
