Kim Jhonson pre and post

Kim Johnson is getting ready for discharge. Which of the following statement(s) by the patient indicate she has understood the patient teaching? (Select all that apply.)

'I am at increased risk for urinary tract infections, so I need to wash my hands before and after catheterization, and then use soap and water to clean my skin.', 'If I am in respiratory distress, I should call 911.', 'I am at increased risk for aspiration due to loss of motor function.', 'Because I'm at an increased risk for falls, I should have physical/occupational therapy visit my home to ensure a safe home environment.'

A patient experiencing paralysis from a T8-level spinal cord injury has been prescribed passive range-of-motion (ROM) exercises for the lower extremities. When the patient asks why the exercises are important, how will the nurse best respond?

'They help your lower body joints maintain their mobility and help prevent contractures.'

The nurse is performing a neurologic assessment. Which instruction will the nurse give a patient in preparation for testing localization?

:'Please close your eyes.'

A patient has experienced a spinal cord injury at the T8 level. Which objective assessment data are associated with such trauma? (Select all that apply.)

Anesthesia extending from the waist downward, Analgesia extending from the waist downwa

While Kim Johnson is at the rehabilitation center, what step(s) does the nurse need to perform in her care? (Select all that apply.)

Call the provider with sensory and motor assessment results., Educate patient on high-fiber diet., Reinforce active and passive range-of-motion exercises with patient., Perform patient perineal care as needed.

A patient presents with a severe headache. What components are required in the objective portion of a neurologic assessment? (Select all that apply.)

Conduct the mental status examination to evaluate cognitive function., Assess the cranial nerves when evaluating the head, neck, eyes, and ears., Evaluate the function of the cerebellar system by assessing balance., Evaluate pupils during a 'neuro check.'

The patient has experienced a spinal cord injury resulting in paralysis from the waist down. Based on this patient's injury, which area(s) will the nurse focus on monitoring? (Select all that apply.)

Redness over bony areas, Range of motion in affected extremities, Bowel and bladder function

What intervention(s) by the nurse will prevent complications of catheterization for Kim Johnson? (Select all that apply.)

Scan bladder before and after catheterization., Record the amount and color of urine emptied from the bladder., Assess the bladder every 4 hours to see if it needs to be emptied., Keep the area dry and clean., Wear gloves and wash hands before and after catheterization.

When the nurse is performing passive range of motion (ROM) during a musculoskeletal examination, the patient reports pain in their left leg. Which action will the nurse take to ensure safety?

Stop the motion immediately.

A patient experiencing a spinal cord injury asks the nurse, 'What does it mean when they say I have an injury at the T8 level?' Which response by the nurse will best answer the patient's question?

The injury occurred to your back where the eighth thoracic nerve is located.'

A patient reports numbness. What is the best way to perform a neurologic assessment of this patient?

Use a recognized mnemonic to ask the patient questions about the numbness.

The nurse notices that Kim Johnson has not had a bowel movement since arriving at the rehabilitation center. What intervention(s) can the nurse put into place to prevent constipation in Kim Johnson? (Select all that apply.)

Monitor the patient's intake of her high-fiber diet., Call the provider., Perform an abdominal assessment., Review chart to see when docusate sodium was last given.

When performing a sensory and motor assessment on Kim Johnson, what is the most important information for the nurse to note? (Select all that apply.)

No sensation in lower extremities, Unable to raise lower extremities, Muscle tone is flaccid in lower extremities, Full passive range of motion (ROM) in lower extremities

What condition(s) are consistent with the sensory and motor assessment you performed on Kim Johnson? (Select all that apply.)

Paraplegia, Complete spinal cord injury at T8

The patient is unable to effectively move their legs individually against the resistance provided by the nurse. Which instruction will the nurse provide to continue to evaluate the patient's muscle strength?

Please lift your leg up off of the exam table.'

A patient who experienced a spinal cord injury is now undergoing passive range-of-motion (ROM) exercises to help maintain joint motion. The nurse will include which intervention(s) in the patient's ROM routine? (Select all that apply.)

Dorsiflex and plantar flex the ankle joints., Perform the exercise at least three times at each joint., Incorporate as part of the bathing routine., Perform at least two times daily.