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A nurse is preparing to assess a patient using the ASIA Impairment Scale. The nurse is attempting to identify the degree of sensory & motor function present in the patient after this injury has occurred. What should the nurse remember before following through with this type of assessment?
what is they cannot do it, has to be completed by a medical doctor
The patient is brought into the ER via Pafford. The patient has been assessed using the ASIA Scale and the results are as followed, "Incomplete, with 50% of muscles < grade 3, the patient can not raise arms or legs off the bed." What letter does the nurse understand these assessment findings as?
what is C
A patient has just experienced an acute SCI. Which vital signs correctly align with this patient's current status? Select all that apply.
a. Pulse of 54
b. B/P of 84/43
c. Heart Rhythm of NSR
d. Temp of 101.2
what is A, B (bradycardia, hypotension, & asystole)
A nurse is teaching a group of nursing students about the goals of medical management in the acute phase of an SCI. Which of the following would demonstrate a need for further teaching?
a. prevention of secondary injury
b. observe for progressing neurological deficits
c. identify any s/s of internal hemorrhage
d. prevent complications
what is c; made that up L O L
A SCI patient is currently undergoing the treatment of cervical traction. The nurse understands this patient needs routine pin site care. Which of the following are true regarding the pin site care?
a. perform it daily
b. clean technique
c. use normal saline as the cleaning solution
d. remove the pins when performing the care
what is A
A nurse is preparing to administer Dexamethasone Sodium Phosphate to a patient who just suffered an SCI. Explain why this medication would be administered to this patient.
What is corticosteroids are given to help stop the inflammation (which could lead to a secondary injury if edema occurs)
Place the following in the correct sequence: (Emergency/At the Scene Treatment)
a. immobilize client on backboard
b. check responsiveness & ABCs
c. keep client flat and log roll
d. prevent flexion, extension, rotation of the head
what is B, D, C, A
A patient has just undergone surgical treatment following an SCI. Why is Rehab needed "ASAP" in this client?
what is preserves function.
To prevent further damage to the spinal cord, the nurse monitors what, ensuring it stays at this level.
what is MAP @ 85 mmHg or higher
A patient presents to the ER with the following assessment:
"Patient lying flat on a backboard in bed. Paralyzation is noted. The patient has flaccid muscles with absent reflexes. Vital Signs are as followed: BP 84/53, Temp of 102.3, RR 16, 0/10 pain, Pulse of 45, O2 Sat of 97%."
Based on this assessment, what should the nurse suspect this patient is experiencing?
what is spinal shock
Which two complications of Spinal Shock should the nurse observe for after a patient experiences an SCI.
what is bowel distention & paralytic ileus (often occurs within the first 2-3 days).
A nurse is assessing a patient who experienced spinal shock. What should the nurse assess for in order to determine whether this patient has met the "resolution" of this condition?
what is return of some reflex activity (although hyperreflexivity & spasticity occurs)
What two hemodynamic changes does a nurse expect to see in a patient experiencing neurogenic shock?
what is venous pooling and peripheral vasodilation
A patient reports to the ER with flushed warm skin, lips and fingernails cyanotic, and LOC. The nurse suspects these findings to correlate with what condition?
what is neurogenic shock (circulatory problem)
A nurse just received the plan of care for a patient experiencing neurogenic shock, it reads as follows: "Manage ABCs, immobilize the spine, IV fluids, Administer Dopamine and Atropine, offer rewarming devices."
Explain why each intervention is correct or incorrect & why ðĪŠ
what is... ALL OF EM CORRECT ;)
- immobilize the spine (prevent further injury)
- IV fluids (to â cardiac preload & CO)
- Dopamine (vasopressor = â systemic vascular resistance)
- Atropine (for bradycardia)
- Rewarming devices (for hypothermia if needed)
what is autonomic dysreflexia - vasodilation above level of injury
A nurse has just received report from the night shift nurse, who claims the patient in room 202 has begun experiencing symptoms of autonomic dysreflexia. In which order should the new nurse perform the following steps:
a. Notify HCP
b. Check vital signs
c. Identify cause
d. Loosen restrictive bedding/clothing
e. Monitor BP q 2-5 minutes
f. Administer antihypertensive medication
g. Teach client/family preventative measures
h. Elevate the HOB
what is b, h, c, d, e, f, a, g
A woman has just experienced an SCI. When should the nurse inform her that menses may return and what important information should the nurse include in the teaching?
what is within 3 months; tampons are not recommended; birth control pills & IUDs are not recommended (bc they can cause thrombus formation)
A nurse is preparing to administer an insulin injection to a client with an SCI at level T1. Where should the nurse plan to administer the medication to this client?
a. Left Lower Quadrant
b. Back of the Tricep (fatty area)
c. Lower Back (love handle areas)
d. Outer upper sides of thigh
what is B
Which two respiratory complications should a nurse monitor for in an SCI patient? SATA.
a. atelectasis
b. neurogenic shock
c. fecal impactions
d. pneumonia
e. anemia
what is a, d
Which action by the nurse is needed for the client with a halo device?
what is...
- Frequently inspect the skin under the vest
- Ensure the torque screwdriver is @ bedside
Which should the nurse anticipate when placing the client with a T2 SCI in the upright position?
what is OH occuring
A nurse should educate a paraplegic patient on promoting mobility in what ways?
what is encouraging upper extremity exercises
Which intervention does the nurse perform for the client on a bowel training program?
what is administer 10 mg Bisacodyl PR daily in the am
The nurse auscultates rhonchi on a client with a T3 SCI. Which nursing intervention is needed?
what is perform quad assist coughing