HESI Case Studies Spinal Cord Injury (RYAN)

4. Which assessment data warrants immediate intervention by the ED RN? (Select all)

-Jonathan complains of a loss of sensation below his shoulders. His skin is flushed and warm to touch, particularly in the extremities. (A loss of sensation and reflexes below the waist is a sign of spinal shock.) Jonathan's blood pressure is 88/48, and his pulse is 50 (Hypotension and bradycardia are signs of neurogenic shock. This is a medical emergency that warrants immediate intervention.) -Jonathan appears to have bladder distention (Due to the spinal cord injury resulting in spinal shock, bladder paralysis is causing urinary retention, which needs to be addressed. An order for placement of indwelling catheter needs to be initiated.) -His skin is flushed and his extremities are warm to touch.(Signs of vasodilation and warmth of skin below the level of injury, and pooling of venous return in the periphery, are signs of neurogenic shock.)

1. What should Jonathan's friends do while waiting for emergency personnel to arrive? (Select all)

-Place blanket over Jonathan and make sure no one moves him -Ensure that the scene around Jonathan is safe and that he is not in any immediate danger

To evaluate the teaching, the nurse asks ryan to explain his understanding of all instructions given. Which statements indicate Ryan's understanding?

A. it is important to drinking hot fluids prior to defecation B. I will plan bowel evacuation at the same time every day C. i should empty my bladder at least every 2- 3 hours E. If i have a pounding headache, i should move to a sitting position

3. Which intervention has highest priority when assessing Jonathan?

Assess Jonathan's breathing pattern and his ability to cough

8. Which nursing intervention is included in the care plan when managing a client with Gardner-Wells tongs?F

Do not remove the traction weights and ensure they hang freely. (Traction is applied to the tongs by employing weights to maintain alignment. Removing the weights would result in misalignment, possibly creating further damage. Weights should hang freely so they do not interfere with the traction. The client should also be assessed for evidence of infection at the spring-loaded pin sites.)

9. Which intervention should be implemented for a paralytic ileus?

Insert a nasogastric tube and set the siphon drainage to a low, intermittent suction

Which intervention should be implemented for a paralytic ileus?

Obtain an order to insert a nasogastric tube and set the siphon drainage to a low, intermittent suction. (A nasogastric tube is inserted to relieve distention and prevent aspiration.)

You see Ryan's parents crying. What action should the nurse implement at this time?

Sit down beside Ryan's parents. (Offering a caring, supportive presence to the client's parents is the priority intervention at this time. It provides an opportunity for them to share their feelings, if they desires to do so.)

What questions should be asked prior to administering the intravenous contrast through Ryan's saline lock?

what happens when he eats shellfish? (Studies have shown a correlation between shellfish allergies and an allergic reaction to the contrast used in CT scan procedures.) Does he have an allergy to iodine (The contrast that is used for CT scan procedures contains iodine.)

The lab results have been received. Which of these results does the nurse need to be reported to the HCP immediately? (Select all that apply. One, some, or all options may be correct.) Select all that apply

-Respiratory acidosis with marked hypoxemia. Respiratory Acidosis with hypoxemia is a complication that needs to be reported immediately to the HCP. -Blood pressure 94/55, heart rate 64, respirations 32, and temperature 95.2oF (35oC). -Hemaglobin 10 g/sL (100 g/L) and Hematocrit 42% (0,42). These results indicate hemorrhage is occurring and must be reported immediately to the HCP. -Cloudy urine with hematuria. Hematuria can be indicative of internal hemorrhage and needs to be reported immediately to the HCP.

14. Which intervention should the nurse implement?

Arrange a meeting with Jonathan, his family, and the healthcare team to discuss Jonathan's concerns. (Client advocacy is a priority for the nurse. Actively advocating for clients who are vulnerable or unable to promote their own needs is the correct ethical action to implement. Additionally, such a meeting can facilitate open communication among all of the parties involved and any misconceptions can be discussed.)

what questions are appropriate to ask ryan prior to beginning the procedure

Is he claustrophobic or afraid of closed-in, small places? (Most MRIs are closed, which requires a client to be placed in a hollow cavity to conduct the exam. It is important for the technician to explain and prepare the client on what to expect from the MRI scan experience.) Does he have any metal piercings on his body or metal implants? (The MRI uses a magnetic field and radio waves to create an image of soft tissue and organs. Anything metal placed in the field while the machine is activated will be attracted to the magnetic field and could potentially cause harm to the client.)

2. If respiratory compromise occurs, what action should the nurse take to keep the airway open without compromising Jonathan's spine further?

Perform the jaw-thrust technique

Which nursing interventions will prevent skin breakdown for the immobilized client? (Select all that apply. One, some, or all options may be correct.) Select all that apply

Reposition the immobilized client frequently (every 1-2 hours). Frequent and therapeutic positioning not only helps prevent complications but also provides alignment to prevent further spinal cord injury or irritability. Clean the skin as soon as possible after soiling occurs and at routine intervals. Keeping the skin clean and dry will help prevent skin breakdown. Help the client maintain an adequate intake of protein and calories. Adequate nutrition is beneficial to preventing skin breakdown. Apply a commercial skin barrier to areas in frequent contact with urine or feces. A commercial skin barrier helps prevent skin breakdown from urine or feces. Pad contact surfaces with foam, silicon gel, air pads, or other pressure-relieving pads. All bony prominences and heels should be protected from pressure to prevent skin breakdown. Ensure the client maintains a fluid intake between 2000 and 3000 mL per day. Being well hydrated helps protect the skin from breakdown.

5. What intervention should the nurse implement first?

Notify the ED healthcare provider (HCP) immediately (This is a medical emergency. The neurogenic shock must be addressed immediately due to the effects of the hypotension and bradycardia. Spinal shock is the complete loss of all reflex, motor, sensory, and autonomic activity below the lesion. It is also imperative to initiate medical interventions to hopefully lessen the severity of the injury.)

When the nurse recognizes that the client is experiencing autonomic dysreflexia, what are the priority interventions? (Select all that apply. One, some, or all options may be correct.)

Page/notify the health care provider immediately for orders. It is important to notify the HCP when an emergency situation occurs. Place patient in sitting position or return to previous safe position. The first priority is to place patient in sitting position or return to previous safe position. Check the urinary catheter tubing (if present) for kinks or obstruction. Kinks or obstruction of the urinary catheter can cause autonomic dysreflexia, so this is an appropriate intervention. Monitor the client's blood pressures every 10 to 15 minutes. The blood pressure is usually elevated with bradycardia so it is iimportant for the nurse to monitor the client's blood pressure frequently. (our book says every 5 minutes, but this is the answer evolve wanted)

The nurse is assessing the client's abdomen and notes that it is distended and bowel sounds are hypoactive. Which signs and symptoms alert the nurse that an emergency situation has arisen? (Select all that apply. One, some, or all options may be correct.) Select all that apply

Sudden, significant rise in systolic and diastolic blood pressure, with bradycardia. Client states he is experiencing blurred vision and is seeing spots before his eyes Client expresses concern that he is having nasal congestion and a severe headache. The nurse observes profuse sweating in the client's face, neck, and shoulders. The client states that he has the urge to move his bowels but can't do it by himself. The client has goosebumps and expresses feelings of apprehension and fear. (These are all symptoms of autonomic dysreflexia, which is an emergency.)

12. Which outcome should the RN use for evaluation of the efficacy of interventions designed for this nursing diagnosis?

The client exhibits no reddened areas or breaks in the skin

Which statement by the client and significant other indicates a need for the nurse to reteach them about the halo device?

We will need to avoid sexual activity while I am wearing the halo. (This requires the nurse to reteach the client and significant other, because they just need to use a position of comfort during sexual activity.)

Which nursing diagnosis is of highest priority at this time

risk for impaired skin integrity. (Immobility always increases the client's risk for impaired skin integrity. Skin sores are the most common and devastating complication of spinal cord injury. Maslow's Hierarchy of Needs addresses physiological needs first.)