Question 1
Regular
A nurse promotes the prevention of lower back pain by teaching clients at a community center. Which instruction should the nurse include in this education?
Correct!
Incorrect
The correct answer is: A
Rationale
Participate in an exercise program to strengthen muscles. Strengthening muscles, particularly in the core and lower back, enhances stability and support, significantly reducing the risk of developing lower back pain, making this instruction essential for prevention.
B: Purchase a mattress that allows you to adjust the firmness. While a supportive mattress is beneficial, it does not actively strengthen the muscles needed for back pain prevention.
C: Wear flat instead of high-heeled shoes to work each day. Although wearing flat shoes can improve posture, it does not directly address muscle strength, which is crucial for preventing lower back pain.
D: Keep your weight within 20% of your ideal body weight. Maintaining a healthy weight can alleviate stress on the back, but it does not provide the muscle strengthening necessary for effective prevention.
Correct Answer: A
Rationale: Participate in an exercise program to strengthen muscles. Strengthening muscles, particularly in the core and lower back, enhances stability and support, significantly reducing the risk of developing lower back pain, making this instruction essential for prevention.
B: Purchase a mattress that allows you to adjust the firmness. While a supportive mattress is beneficial, it does not actively strengthen the muscles needed for back pain prevention.
C: Wear flat instead of high-heeled shoes to work each day. Although wearing flat shoes can improve posture, it does not directly address muscle strength, which is crucial for preventing lower back pain.
D: Keep your weight within 20% of your ideal body weight. Maintaining a healthy weight can alleviate stress on the back, but it does not provide the muscle strengthening necessary for effective prevention.
Question 2
Regular
A nurse plans care for a client with lower back pain from a work-related injury. Which intervention should the nurse include in this work plan care?
Correct!
Incorrect
The correct answer is: C
Rationale
Apply a heating pad for 20 minutes at least four times daily. This intervention effectively alleviates muscle tension and promotes blood flow, providing relief for clients suffering from work-related lower back pain.
A: Encourage the client to stretch the back by reaching toward the toes. While stretching can improve flexibility, it may exacerbate pain if not done cautiously in acute situations.
B: Massage the affected area with ice twice a day. Icing typically reduces inflammation, but massaging with ice may not provide the necessary warmth to relax tense muscles effectively.
D: Advise the client to avoid warm baths or showers. Warm baths often soothe muscles and promote relaxation, which can be beneficial for managing lower back pain rather than avoiding heat.
Correct Answer: C
Rationale: Apply a heating pad for 20 minutes at least four times daily. This intervention effectively alleviates muscle tension and promotes blood flow, providing relief for clients suffering from work-related lower back pain.
A: Encourage the client to stretch the back by reaching toward the toes. While stretching can improve flexibility, it may exacerbate pain if not done cautiously in acute situations.
B: Massage the affected area with ice twice a day. Icing typically reduces inflammation, but massaging with ice may not provide the necessary warmth to relax tense muscles effectively.
D: Advise the client to avoid warm baths or showers. Warm baths often soothe muscles and promote relaxation, which can be beneficial for managing lower back pain rather than avoiding heat.
Question 3
Regular
A nurse assesses a client who is recovering from a diskectomy 6 hours ago. Which assessment finding should the nurse address first?
Correct!
Incorrect
The correct answer is: C
Rationale
C: Difficulty breathing. This assessment finding indicates a potential respiratory compromise, which is a critical issue that needs immediate attention to ensure the client's safety and stability after surgery.
A: Pain at the surgical site. While pain management is important post-surgery, it is a common occurrence and typically does not pose an immediate threat to the client’s well-being.
B: Numbness in the lower extremities. Numbness may indicate nerve involvement or complications, but it is not an acute life-threatening issue compared to respiratory distress, which demands urgent intervention.
D: Weak pedal pulses. Weak pulses can suggest circulation issues; however, they do not require immediate action in the same urgent manner as respiratory difficulties that can rapidly escalate.
Correct Answer: C
Rationale: C: Difficulty breathing. This assessment finding indicates a potential respiratory compromise, which is a critical issue that needs immediate attention to ensure the client's safety and stability after surgery.
A: Pain at the surgical site. While pain management is important post-surgery, it is a common occurrence and typically does not pose an immediate threat to the client’s well-being.
B: Numbness in the lower extremities. Numbness may indicate nerve involvement or complications, but it is not an acute life-threatening issue compared to respiratory distress, which demands urgent intervention.
D: Weak pedal pulses. Weak pulses can suggest circulation issues; however, they do not require immediate action in the same urgent manner as respiratory difficulties that can rapidly escalate.
Question 4
Regular
A nurse teaches a client who is recovering from a spinal fusion. Which statement should the nurse include in this client's postoperative instructions?
Correct!
Incorrect
The correct answer is: B
Rationale
You must wear a brace throughout the healing process. Wearing a brace provides essential support to the spine during recovery, helping to stabilize the area and promote proper healing after spinal fusion surgery.
A: Only lift items that are 10 pounds or less. While lifting restrictions are important, this instruction alone does not emphasize the critical need for wearing a brace during recovery.
C: You must remain in bed for 3 weeks after surgery. Prolonged bed rest can hinder recovery; mobility is encouraged, provided it is done safely with appropriate support such as a brace.
D: You are prescribed medications to prevent rejection. This statement pertains to organ transplants rather than spinal fusion, where rejection is not a concern; thus, it does not apply to this scenario.
Correct Answer: B
Rationale: You must wear a brace throughout the healing process. Wearing a brace provides essential support to the spine during recovery, helping to stabilize the area and promote proper healing after spinal fusion surgery.
A: Only lift items that are 10 pounds or less. While lifting restrictions are important, this instruction alone does not emphasize the critical need for wearing a brace during recovery.
C: You must remain in bed for 3 weeks after surgery. Prolonged bed rest can hinder recovery; mobility is encouraged, provided it is done safely with appropriate support such as a brace.
D: You are prescribed medications to prevent rejection. This statement pertains to organ transplants rather than spinal fusion, where rejection is not a concern; thus, it does not apply to this scenario.
Question 5
Regular
A nurse assesses a client who is recovering from anterior cervical diskectomy and fusion. Which complication should the nurse address first?
Correct!
Incorrect
The correct answer is: C
Rationale
Difficulty breathing. This symptom indicates a potential airway compromise, which can be life-threatening and requires immediate intervention. Given the surgical context, respiratory complications take precedence over other concerns in recovery.
A: Associated stridor. While stridor can indicate airway issues, it is a secondary concern compared to immediate difficulty breathing, which demands prompt assessment and action to ensure airway patency.
B: Weak pedal pulses. Although weak pedal pulses suggest possible circulation issues, they do not pose an immediate respiratory threat that could compromise the client’s life in the recovery phase.
D: Inability to shrug shoulders. This symptom relates to nerve function and may indicate complications from the surgery, yet it does not present an urgent risk to the client's airway or breathing.
Correct Answer: C
Rationale: Difficulty breathing. This symptom indicates a potential airway compromise, which can be life-threatening and requires immediate intervention. Given the surgical context, respiratory complications take precedence over other concerns in recovery.
A: Associated stridor. While stridor can indicate airway issues, it is a secondary concern compared to immediate difficulty breathing, which demands prompt assessment and action to ensure airway patency.
B: Weak pedal pulses. Although weak pedal pulses suggest possible circulation issues, they do not pose an immediate respiratory threat that could compromise the client’s life in the recovery phase.
D: Inability to shrug shoulders. This symptom relates to nerve function and may indicate complications from the surgery, yet it does not present an urgent risk to the client's airway or breathing.
Question 6
Regular
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. Which action should the nurse take first?
Correct!
Incorrect
The correct answer is: C
Rationale
C: Palpate the bladder for distention. The symptoms of hypertension, flushed face, and blurred vision suggest possible autonomic dysreflexia, often triggered by bladder distention in clients with spinal cord injuries. Immediate assessment is crucial.
A: Administer oxygen via a nasal cannula. While oxygen may benefit some patients, it does not address the underlying cause of the client's acute symptoms.
B: Place the client in a supine position. Positioning the client supine does not alleviate the potential triggers of autonomic dysreflexia, which need immediate attention rather than positional changes.
D: Administer a prescribed beta blocker. Although a beta blocker may help manage hypertension, it does not address the immediate underlying issue causing the autonomic dysreflexia symptoms in this scenario.
Correct Answer: C
Rationale: C: Palpate the bladder for distention. The symptoms of hypertension, flushed face, and blurred vision suggest possible autonomic dysreflexia, often triggered by bladder distention in clients with spinal cord injuries. Immediate assessment is crucial.
A: Administer oxygen via a nasal cannula. While oxygen may benefit some patients, it does not address the underlying cause of the client's acute symptoms.
B: Place the client in a supine position. Positioning the client supine does not alleviate the potential triggers of autonomic dysreflexia, which need immediate attention rather than positional changes.
D: Administer a prescribed beta blocker. Although a beta blocker may help manage hypertension, it does not address the immediate underlying issue causing the autonomic dysreflexia symptoms in this scenario.
Question 7
Regular
An emergency room nurse initiates care for a client with a cervical spinal cord injury who arrives via emergency medical services. Which action should the nurse take first?
Correct!
Incorrect
The correct answer is: D
Rationale
Assessing respiratory status is crucial first in a patient with a cervical spinal cord injury, as this condition can severely compromise breathing due to potential diaphragm paralysis. Ensuring adequate ventilation is vital for patient survival and informs subsequent interventions.
A: Assess level of consciousness. While important, evaluating consciousness comes after ensuring the airway and breathing are stable in emergencies involving spinal cord injuries.
B: Obtain vital signs. Although assessing vital signs is necessary, it does not address the immediate risk of respiratory compromise that arises from cervical spinal cord injuries.
C: Administer oxygen therapy. This action may be essential later, but it is ineffective without first confirming that the patient's respiratory status is adequate to warrant oxygen supplementation.
Correct Answer: D
Rationale: Assessing respiratory status is crucial first in a patient with a cervical spinal cord injury, as this condition can severely compromise breathing due to potential diaphragm paralysis. Ensuring adequate ventilation is vital for patient survival and informs subsequent interventions.
A: Assess level of consciousness. While important, evaluating consciousness comes after ensuring the airway and breathing are stable in emergencies involving spinal cord injuries.
B: Obtain vital signs. Although assessing vital signs is necessary, it does not address the immediate risk of respiratory compromise that arises from cervical spinal cord injuries.
C: Administer oxygen therapy. This action may be essential later, but it is ineffective without first confirming that the patient's respiratory status is adequate to warrant oxygen supplementation.
Question 8
Regular
An emergency department nurse cares for a client who experienced a spinal cord injury 1 hour ago. Which prescribed medication should the nurse prepare to administer?
Correct!
Incorrect
The correct answer is: B
Rationale
Methylprednisolone (Medrol) should be prepared for administration. This corticosteroid is vital in acute spinal cord injury management as it reduces inflammation and minimizes neurological damage, enhancing recovery outcomes.
A: Ibuprofen (Advil) This nonsteroidal anti-inflammatory drug is not suitable for acute spinal cord injuries, as it primarily alleviates pain and inflammation rather than addressing critical neurological protection.
C: Atropine sulfate This anticholinergic medication is primarily used for bradycardia and does not play a role in managing spinal cord injuries or their complications effectively.
D: Etanercept (Enbrel) This biologic agent is intended for autoimmune conditions and does not provide the immediate anti-inflammatory effects necessary for acute spinal cord injury treatment.
Correct Answer: B
Rationale: Methylprednisolone (Medrol) should be prepared for administration. This corticosteroid is vital in acute spinal cord injury management as it reduces inflammation and minimizes neurological damage, enhancing recovery outcomes.
A: Ibuprofen (Advil) This nonsteroidal anti-inflammatory drug is not suitable for acute spinal cord injuries, as it primarily alleviates pain and inflammation rather than addressing critical neurological protection.
C: Atropine sulfate This anticholinergic medication is primarily used for bradycardia and does not play a role in managing spinal cord injuries or their complications effectively.
D: Etanercept (Enbrel) This biologic agent is intended for autoimmune conditions and does not provide the immediate anti-inflammatory effects necessary for acute spinal cord injury treatment.
Question 9
Regular
A nurse teaches a client with a lower motor neuron lesion who wants to achieve bladder control. Which statement should the nurse include in this client's teaching?
Correct!
Incorrect
The correct answer is: C
Rationale
C: Tighten your abdominal muscles to stimulate urine flow. This technique can effectively promote bladder control in clients with lower motor neuron lesions by utilizing the voluntary contraction of abdominal muscles to facilitate urination, thereby enhancing bladder function.
A: Stroke the inner aspect of your thigh to initiate voiding. This method may not reliably trigger bladder contraction in individuals with lower motor neuron lesions, as their neurological responses are impaired.
B: Implement digital anal stimulation when your bladder is full. While this may assist with bowel movements, it does not directly address bladder control, which requires specific bladder management techniques.
D: Use a catheter to empty your bladder completely. While catheterization can help manage bladder emptying, it does not promote independent bladder control, which is the client's primary goal.
Correct Answer: C
Rationale: C: Tighten your abdominal muscles to stimulate urine flow. This technique can effectively promote bladder control in clients with lower motor neuron lesions by utilizing the voluntary contraction of abdominal muscles to facilitate urination, thereby enhancing bladder function.
A: Stroke the inner aspect of your thigh to initiate voiding. This method may not reliably trigger bladder contraction in individuals with lower motor neuron lesions, as their neurological responses are impaired.
B: Implement digital anal stimulation when your bladder is full. While this may assist with bowel movements, it does not directly address bladder control, which requires specific bladder management techniques.
D: Use a catheter to empty your bladder completely. While catheterization can help manage bladder emptying, it does not promote independent bladder control, which is the client's primary goal.
Question 10
Regular
A nurse assesses a client with multiple sclerosis after administering prescribed fingolimod (Gilenya). For which adverse effect should the nurse monitor?
Correct!
Incorrect
The correct answer is: C
Rationale
C: Bradycardia. Fingolimod can cause bradycardia, particularly after the first dose, due to its action on the heart's vagal tone. Monitoring for this adverse effect is essential to ensure patient safety and timely intervention.
A: Peripheral edema exhibits a different mechanism and is not a primary concern associated with fingolimod. This medication primarily affects heart rate rather than fluid retention.
B: Black and tarry stools indicate gastrointestinal bleeding, which is not a common side effect of fingolimod. The medication's profile does not typically lead to such complications.
D: Nausea and vomiting are not significant adverse effects of fingolimod. While they can occur, they are less critical compared to the risk of bradycardia that warrants careful monitoring.
Correct Answer: C
Rationale: C: Bradycardia. Fingolimod can cause bradycardia, particularly after the first dose, due to its action on the heart's vagal tone. Monitoring for this adverse effect is essential to ensure patient safety and timely intervention.
A: Peripheral edema exhibits a different mechanism and is not a primary concern associated with fingolimod. This medication primarily affects heart rate rather than fluid retention.
B: Black and tarry stools indicate gastrointestinal bleeding, which is not a common side effect of fingolimod. The medication's profile does not typically lead to such complications.
D: Nausea and vomiting are not significant adverse effects of fingolimod. While they can occur, they are less critical compared to the risk of bradycardia that warrants careful monitoring.
Question 11
Regular
A nurse is teaching a client with multiple sclerosis who is prescribed cyclophosphamide (Cytoxan) and methylprednisolone (Medrol). Which statement should the nurse include in this client's discharge teaching?
Correct!
Incorrect
The correct answer is: B
Rationale
B: Avoid people with upper respiratory illnesses. This statement is crucial as both cyclophosphamide and methylprednisolone can suppress the immune system, increasing vulnerability to infections, particularly respiratory illnesses, which can exacerbate symptoms of multiple sclerosis.
A: Take warm baths to promote muscle relaxation. While warm baths may aid relaxation, they do not address infection risks associated with immunosuppressive therapy, making this advice insufficient for patient protection.
C: Relying on a walker will weaken your gait. Using a walker is a supportive measure that can enhance stability and safety, rather than compromise physical strength or mobility in clients with multiple sclerosis.
D: Take prescribed medication only when symptoms occur. Consistent medication adherence is essential for managing multiple sclerosis effectively, and delaying treatment can lead to worsening symptoms and potential complications.
Correct Answer: B
Rationale: B: Avoid people with upper respiratory illnesses. This statement is crucial as both cyclophosphamide and methylprednisolone can suppress the immune system, increasing vulnerability to infections, particularly respiratory illnesses, which can exacerbate symptoms of multiple sclerosis.
A: Take warm baths to promote muscle relaxation. While warm baths may aid relaxation, they do not address infection risks associated with immunosuppressive therapy, making this advice insufficient for patient protection.
C: Relying on a walker will weaken your gait. Using a walker is a supportive measure that can enhance stability and safety, rather than compromise physical strength or mobility in clients with multiple sclerosis.
D: Take prescribed medication only when symptoms occur. Consistent medication adherence is essential for managing multiple sclerosis effectively, and delaying treatment can lead to worsening symptoms and potential complications.
Question 12
Regular
A nurse cares for several clients on a neurologic unit. Which prescription for a client should direct the nurse to ensure that a medical consent cannot be substituted before the test or procedure?
Correct!
Incorrect
The correct answer is: C
Rationale
C: Lumbar puncture for cerebrospinal fluid sampling. This procedure is invasive and carries potential risks, necessitating informed consent from the client, which cannot be substituted or assumed in any circumstance.
A: Sensation measurement via the pinprick method. This assessment is non-invasive and typically does not require formal consent since it is part of routine neurological evaluations.
B: Computed tomography of the cranial vault. While this imaging test may require consent, it is often considered standard practice, and consent can sometimes be implied under certain conditions.
D: Venipuncture for autoantibody analysis. This procedure is generally low-risk and often performed with implied consent, as it is a common blood draw for diagnostic purposes.
Correct Answer: C
Rationale: C: Lumbar puncture for cerebrospinal fluid sampling. This procedure is invasive and carries potential risks, necessitating informed consent from the client, which cannot be substituted or assumed in any circumstance.
A: Sensation measurement via the pinprick method. This assessment is non-invasive and typically does not require formal consent since it is part of routine neurological evaluations.
B: Computed tomography of the cranial vault. While this imaging test may require consent, it is often considered standard practice, and consent can sometimes be implied under certain conditions.
D: Venipuncture for autoantibody analysis. This procedure is generally low-risk and often performed with implied consent, as it is a common blood draw for diagnostic purposes.
Question 13
Regular
A nurse prepares a client for prescribed magnetic resonance imaging (MRI). Which action should the nurse implement prior to the test?
Correct!
Incorrect
The correct answer is: A
Rationale
Screen for metal implants or devices. This action is crucial as MRI uses strong magnetic fields that can interact dangerously with metallic objects, posing significant risks to the patient's safety and the integrity of the imaging process.
B: Implement nothing by mouth (NPO) status for 8 hours. This protocol is typically associated with surgical procedures, not necessary for MRI, which relies on imaging rather than invasive techniques.
C: Administer a sedative to reduce anxiety. While sedation may help some patients, it is not a standard requirement for MRI preparation and could interfere with monitoring during the procedure.
D: Ensure the client has an empty bladder. Although this may be relevant for some imaging types, it is not a general prerequisite for MRI procedures, which vary based on the area being scanned.
Correct Answer: A
Rationale: Screen for metal implants or devices. This action is crucial as MRI uses strong magnetic fields that can interact dangerously with metallic objects, posing significant risks to the patient's safety and the integrity of the imaging process.
B: Implement nothing by mouth (NPO) status for 8 hours. This protocol is typically associated with surgical procedures, not necessary for MRI, which relies on imaging rather than invasive techniques.
C: Administer a sedative to reduce anxiety. While sedation may help some patients, it is not a standard requirement for MRI preparation and could interfere with monitoring during the procedure.
D: Ensure the client has an empty bladder. Although this may be relevant for some imaging types, it is not a general prerequisite for MRI procedures, which vary based on the area being scanned.
Question 14
Regular
A nurse assesses the health history of a client who is prescribed ziconotide (Prialt) for chronic back pain. Which assessment question should the nurse ask?
Correct!
Incorrect
The correct answer is: B
Rationale
B: Do you have a history of psychiatric disorders? This question is crucial as ziconotide has been associated with neuropsychiatric side effects, making it essential to identify any pre-existing mental health issues that could be exacerbated by the medication.
A: Are you taking a nonsteroidal anti-inflammatory drug? While relevant, this question does not address the specific concerns related to ziconotide's psychiatric side effects, which are more critical for patient safety.
C: Do you have difficulty swallowing medications? Although this might be a valid concern for some medications, ziconotide is administered intrathecally, rendering swallowing difficulties less pertinent to its usage and effectiveness.
D: Do you smoke cigarettes or any illegal drugs? This inquiry, while important for overall health assessment, does not directly relate to the specific risks associated with ziconotide treatment and its potential psychiatric implications.
Correct Answer: B
Rationale: B: Do you have a history of psychiatric disorders? This question is crucial as ziconotide has been associated with neuropsychiatric side effects, making it essential to identify any pre-existing mental health issues that could be exacerbated by the medication.
A: Are you taking a nonsteroidal anti-inflammatory drug? While relevant, this question does not address the specific concerns related to ziconotide's psychiatric side effects, which are more critical for patient safety.
C: Do you have difficulty swallowing medications? Although this might be a valid concern for some medications, ziconotide is administered intrathecally, rendering swallowing difficulties less pertinent to its usage and effectiveness.
D: Do you smoke cigarettes or any illegal drugs? This inquiry, while important for overall health assessment, does not directly relate to the specific risks associated with ziconotide treatment and its potential psychiatric implications.
Question 15
Multiple Choice
After teaching a male client with a spinal cord injury at the T4 level, the nurse assesses the client's understanding. Which statements indicate a correct understanding of the teaching related to sexual effects of this injury? (Select all that apply.)
Correct!
Incorrect
The correct answer is: C,D,E
Rationale
C: Ejaculation may not be as predictable as before. This statement accurately reflects the potential changes in sexual function following a T4 spinal cord injury, where nerve pathways can disrupt normal ejaculation patterns.
A: I will explore other ways besides intercourse to please my partner. This approach, while valid, does not directly address the specific sexual effects of the T4 injury and may imply a lack of understanding.
B: I will not be able to have an erection because of my injury. This statement is overly definitive; some individuals with T4 injuries may still achieve erections with appropriate stimulation.
E: I should be able to have an erection with stimulation. This assertion suggests a potential capability that may not apply uniformly to all individuals with a T4 injury, indicating a misunderstanding.
Correct Answer: C,D,E
Rationale: C: Ejaculation may not be as predictable as before. This statement accurately reflects the potential changes in sexual function following a T4 spinal cord injury, where nerve pathways can disrupt normal ejaculation patterns.
A: I will explore other ways besides intercourse to please my partner. This approach, while valid, does not directly address the specific sexual effects of the T4 injury and may imply a lack of understanding.
B: I will not be able to have an erection because of my injury. This statement is overly definitive; some individuals with T4 injuries may still achieve erections with appropriate stimulation.
E: I should be able to have an erection with stimulation. This assertion suggests a potential capability that may not apply uniformly to all individuals with a T4 injury, indicating a misunderstanding.
Question 16
Multiple Choice
A nurse cares for a client with a lower motor neuron injury who is experiencing a flaccid bowel elimination pattern. Which actions should the nurse take to assist in relieving this client's complication? (Select all that apply.)
Correct!
Incorrect
The correct answer is: B,D,F
Rationale
A diet high in fluids and fiber promotes regular bowel movements, which is essential for clients with flaccid bowel elimination patterns due to lower motor neuron injuries. This dietary approach helps soften stool and encourages natural elimination.
A: Pouring warm water over the perineum may provide temporary relief but does not address the underlying issue of bowel movement regulation in flaccid bowel patterns.
C: Administering daily tap water enemas can lead to dependency and may disrupt the natural bowel function, failing to promote healthy, independent elimination patterns.
E: Performing manual disimpaction should be a last resort option, as it can cause discomfort and should not replace a comprehensive bowel management plan focused on prevention and regularity.
Correct Answer: B,D,F
Rationale: A diet high in fluids and fiber promotes regular bowel movements, which is essential for clients with flaccid bowel elimination patterns due to lower motor neuron injuries. This dietary approach helps soften stool and encourages natural elimination.
A: Pouring warm water over the perineum may provide temporary relief but does not address the underlying issue of bowel movement regulation in flaccid bowel patterns.
C: Administering daily tap water enemas can lead to dependency and may disrupt the natural bowel function, failing to promote healthy, independent elimination patterns.
E: Performing manual disimpaction should be a last resort option, as it can cause discomfort and should not replace a comprehensive bowel management plan focused on prevention and regularity.
Question 17
Multiple Choice
A nurse assesses a client who is recovering from a lumbar laminectomy. Which complications should alert the nurse to urgently communicate with the health care provider? (Select all that apply.)
Correct!
Incorrect
The correct answer is: C,D,E
Rationale
Incisional bulging, clear drainage on the dressing, and sudden severe headache are complications that require urgent communication with the health care provider during recovery from a lumbar laminectomy.
C: Incisional bulging suggests potential hematoma or wound dehiscence, signaling a serious issue requiring immediate attention.
D: Clear drainage on the dressing could indicate cerebrospinal fluid leakage, a critical concern needing prompt assessment and intervention.
E: Sudden and severe headache may indicate increased intracranial pressure or other complications, necessitating urgent evaluation.
A: Surgical discomfort is common post-operation and typically managed with medication, not an immediate concern for urgent communication.
B: Redness and itching at the incision site can arise from irritation or normal healing, not necessarily indicating a serious complication needing immediate intervention.
Correct Answer: C,D,E
Rationale: Incisional bulging, clear drainage on the dressing, and sudden severe headache are complications that require urgent communication with the health care provider during recovery from a lumbar laminectomy.
C: Incisional bulging suggests potential hematoma or wound dehiscence, signaling a serious issue requiring immediate attention.
D: Clear drainage on the dressing could indicate cerebrospinal fluid leakage, a critical concern needing prompt assessment and intervention.
E: Sudden and severe headache may indicate increased intracranial pressure or other complications, necessitating urgent evaluation.
A: Surgical discomfort is common post-operation and typically managed with medication, not an immediate concern for urgent communication.
B: Redness and itching at the incision site can arise from irritation or normal healing, not necessarily indicating a serious complication needing immediate intervention.
Question 18
Multiple Choice
A nurse assesses a client with paraplegia from a spinal cord injury and notes reddened areas over the client's hips and sacrum. Which actions should the nurse take? (Select all that apply.)
Correct!
Incorrect
The correct answer is: B,D
Rationale
Reposition the client off of the reddened areas and obtain a low-air-loss mattress to minimize pressure. These actions directly address the prevention of further skin breakdown and alleviate pressure on vulnerable areas, crucial for a client with paraplegia who is at risk for pressure ulcers.
A: Perform range-of-motion (ROM) exercises for the hip joint. While beneficial for maintaining mobility, ROM exercises do not address pressure relief on reddened areas or skin integrity.
C: Get the client out of bed and into a chair once a day. This action may provide temporary relief but does not ensure consistent pressure redistribution for the affected areas.
E: Apply a barrier cream to the reddened areas. Barrier creams help protect the skin but do not remove pressure or address the underlying issue of tissue damage from prolonged pressure.
Correct Answer: B,D
Rationale: Reposition the client off of the reddened areas and obtain a low-air-loss mattress to minimize pressure. These actions directly address the prevention of further skin breakdown and alleviate pressure on vulnerable areas, crucial for a client with paraplegia who is at risk for pressure ulcers.
A: Perform range-of-motion (ROM) exercises for the hip joint. While beneficial for maintaining mobility, ROM exercises do not address pressure relief on reddened areas or skin integrity.
C: Get the client out of bed and into a chair once a day. This action may provide temporary relief but does not ensure consistent pressure redistribution for the affected areas.
E: Apply a barrier cream to the reddened areas. Barrier creams help protect the skin but do not remove pressure or address the underlying issue of tissue damage from prolonged pressure.
Question 19
Multiple Choice
A nurse assesses a client who experienced a spinal cord injury at the T5 level 12 hours ago. Which manifestations should the nurse correlate with neurogenic shock? (Select all that apply.)
Correct!
Incorrect
The correct answer is: A,B,C,D,E
Rationale
A: Heart rate of 34 beats/min, B: Blood pressure of 90/60 mm Hg, C: Cool and clammy skin, D: Decreased urinary output, E: Flaccid paralysis below the injury.
Neurogenic shock occurs following spinal cord injury, leading to significant alterations in cardiovascular and temperature regulation. The manifestations include bradycardia, hypotension, peripheral vasodilation causing cool skin, reduced urinary output, and loss of motor function below the injury site.
C: Cool and clammy skin. This symptom indicates peripheral vasodilation, a characteristic of neurogenic shock, rather than the typical warm, dry skin seen in other shock types.
D: Decreased urinary output. While decreased output can occur, it is more indicative of other complications rather than a direct manifestation of neurogenic shock itself.
E: Flaccid paralysis below the injury. Flaccid paralysis signifies loss of motor function but does not directly relate to the hemodynamic changes associated with neurogenic shock.
Correct Answer: A,B,C,D,E
Rationale: A: Heart rate of 34 beats/min, B: Blood pressure of 90/60 mm Hg, C: Cool and clammy skin, D: Decreased urinary output, E: Flaccid paralysis below the injury.
Neurogenic shock occurs following spinal cord injury, leading to significant alterations in cardiovascular and temperature regulation. The manifestations include bradycardia, hypotension, peripheral vasodilation causing cool skin, reduced urinary output, and loss of motor function below the injury site.
C: Cool and clammy skin. This symptom indicates peripheral vasodilation, a characteristic of neurogenic shock, rather than the typical warm, dry skin seen in other shock types.
D: Decreased urinary output. While decreased output can occur, it is more indicative of other complications rather than a direct manifestation of neurogenic shock itself.
E: Flaccid paralysis below the injury. Flaccid paralysis signifies loss of motor function but does not directly relate to the hemodynamic changes associated with neurogenic shock.
Quiz Complete!
Care of Patients with Problems of the CNS: The Spinal Cord
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