Unit N 40
The nurse is providing instructions to a client with a cervical spinal cord injury about caring for the halo fixator device. The nurse plans to include which instructions?
"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.
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 the client at this time?
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 to C5) innervate the phrenic nerve, controlling the diaphragm.
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." 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.
The nurse is teaching a client about starting glatiramer acetate. Which statement by the client indicates a need for further teaching?
"I need to take this drug before breakfast at least once a week while I have weakness." Because this drug is given parenterally, there is no need to take it with or without food. All of the other client statements are accurate and demonstrates client understanding.
A client has been diagnosed with primary progressive multiple sclerosis (PPMS) and the nurse is providing education at the clinic. What statement by the client indicates the need for further teaching?
"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 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 would be the appropriate response for the nurse?
"Please request a meeting with the primary health care provider. I can help 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 client with possible multiple sclerosis asks the nurse to explain why she has to have a visual evoked response (VER) test. What statement by the nurse is correct about this diagnostic test?
"This test will help determine how well the nerves in your eyes transmit a signal." The VER is a noninvasive test that determines how well nerve transmission occurs along the optic nerve pathways.
The nurse administered a prescribed dose of natalizumab for a client who is diagnosed with multiple sclerosis. For what adverse drug event will the nurse assess as the priority for this client within the first hour after administration?
Anaphylactic or allergic reaction While all of these adverse drug events are associated with natalizumab, the one that can occur within the first hour after administration is anaphylaxis. Infection can also cause fatality if it becomes systemic or the client develops progressive multifocal leukoencephalopathy (PML) which can cause mental and other neurologic changes.
A client returns to the neurosurgical floor after undergoing a traditional anterior cervical diskectomy and fusion (ACDF). What is the nurse's first action?
Assess airway and breathing. The nurse's first action when a client returns to the neurosurgical floor after having an anterior cervical diskectomy 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 with severe muscle spasticity has been prescribed tizanidine. The nurse instructs the client about which adverse effect of tizanidine?
Drowsiness Adverse effects of tizanidine include drowsiness and sedation because the drug is a centrally acting skeletal muscle relaxant. It does not cause hirsutism, hypertension, or tachycardia.
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.)
Facial and skin flushing, Nasal congestion and blurred vision, Profuse sweating above the injury level, Severe throbbing headache, Sudden and severe hypertension, Goose bumps above and/or below the injury level All of these findings commonly occur in clients who experience autonomic dysreflexia.
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?
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.
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.)
Infection, diarrhea, facial flushing, Nausea/vomiting 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.
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?
Nifedipine The nurse anticipates that the primary health care provider will prescribe nifedipine or nitrates for a spinal cord injury client who has an elevated blood pressure and severe headache. This client is experiencing autonomic dysreflexia (AD). If AD is not treated, a hemorrhagic stroke can occur.Dopamine hydrochloride is an inotropic agent used to treat severe hypotension. Methylprednisolone is a glucocorticoid and is not indicated because it may further increase blood pressure. Ziconotide is an N-type calcium channel blocker on those nerves that usually transmit pain signals to the brain.
Which nursing intervention is best for preventing complications of immobility when caring for a client with spinal cord injury?
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.
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?
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.
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 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.
