Compartment Syndrome
Severe pain out of proportion to the injury is an early warning sign of this emergency.
What is acute compartment syndrome?
Loss of reflexes and flaccid paralysis below a new spinal injury may represent this temporary state.
What is spinal shock?
MS damages this insulating covering of CNS nerve fibers
What is myelin?
Encephalopathy is a broad term for dysfunction of this organ.
What is the brain?
Hearing voices when no external sound exists is this symptom.
What is an auditory hallucination?
Elevated or irritable mood, increased energy, decreased need for sleep, pressured speech, and risky behavior describe this.
What is a manic episode?
Persistent depressed mood or loss of interest/pleasure is central to this disorder.
What is major depressive disorder?
Marked pain during this maneuver is an important early finding.
What is passive stretch?
Severe hypertension, pounding headache, flushing, and sweating after a high SCI suggest this emergency.
What is autonomic dysreflexia?
Fatigue, weakness, visual changes, numbness, and poor coordination are common manifestations of this disease
What is multiple sclerosis?
Confusion, poor attention, behavior change, and decreased consciousness reflect changes in this area.
What is cognition/mental status?
A fixed false belief held despite evidence is called this.
What is a delusion?
During acute mania, reducing stimulation and setting clear limits support this top priority.
What is safety?
Loss of interest or pleasure in previously enjoyable activities is called this.
What is anhedonia?
When compartment syndrome is suspected, this is the priority nursing action.
What is notify the provider/emergency surgical team immediately?
The first positioning action for suspected autonomic dysreflexia is this.
What is sit the patient upright?
Excessive exposure to this can temporarily worsen MS symptoms.
What is heat?
This bedside assessment should be repeated to detect neurologic deterioration.
What is level of consciousness/neurologic assessment?
Flat affect, social withdrawal, and reduced motivation are classified as these symptoms.
What are negative symptoms?
A severely manic patient who cannot sit for meals may benefit from this type of nutrition.
What are high-calorie finger foods and fluids?
Hopelessness requires priority assessment for this safety risk.
What is suicide/self-harm risk?
Pallor, paresthesia, paralysis, and pulselessness are late signs of worsening loss of this.
What is neurovascular perfusion/function?
One of the most common triggers of autonomic dysreflexia is distention of this organ.
What is the bladder?
This strategy helps an MS patient manage fatigue while preserving function.
What is energy conservation with scheduled rest periods?
Hepatic encephalopathy may be associated with an elevated level of this substance.
What is ammonia?
When a patient reports threatening voices, the nurse should immediately assess whether the voices are telling the patient to do this.
What is harm self or others/act on commands?
A patient taking lithium should keep fluid intake and this dietary electrolyte consistent.
What is sodium?
Patients should know that antidepressants commonly require this long before full therapeutic benefit is seen.
What is several weeks?
This emergency surgery releases pressure by opening the fascia.
What is a fasciotomy?
With a cervical spinal cord injury, this ABC priority requires immediate attention.
What is airway/breathing or respiratory status?
New neurologic symptoms lasting more than 24 hours without fever or infection may indicate this.
What is an MS relapse/exacerbation?
Lactulose is commonly used in hepatic encephalopathy to reduce this substance.
What is ammonia?
Instead of arguing with a delusion, the nurse should acknowledge feelings and do this.
What is present reality without validating the delusion?
Coarse tremor, vomiting, confusion, or ataxia in a patient taking lithium suggests this.
What is lithium toxicity?
A patient says, 'Everyone would be better off without me.' The nurse should directly ask about this.
What are suicidal thoughts/self-harm, including plan and intent?
A patient with a T4 spinal cord injury suddenly develops a pounding headache, BP 210/110, facial flushing, and diaphoresis. Identify the emergency AND the nurse’s immediate first action.
What is autonomic dysreflexia — and sit the patient upright immediately?