Spinal Cord Injury
A nurse is collecting data from a patient who has a herniated intervetebral cervical disc. What should the nurse expect?
What is Tingling in the arms, shoulder pain and Neck stiffness?
A nurse is discussing skeletal and skin traction with a newly licensed nurse. What statement by the new nurse would indicate that she understands these two therapies?
What is “Skeletal traction is better than skin traction for reducing a fracture” because skeletal traction allows for reduction and alignment of a fracture. Skin traction decreases muscle spasms common with a fracture.
A nurse is receiving transfer report for a patient who has a head injury. The patient has a Glasgow Coma Scale score of 3 for eye opening, 5 for best verbal response and 5 for best motor response. What would the conclusion be based on this data?
A nurse is assisting with the care of a patient immediately following a lumbar puncture. Which of the following actions should the nurse take?
What is Encourage fluid intake to replace the fluid taken from the spine and Monitor the puncture site for a hematoma indicating internal bleeding.
A nurse is caring for a patient who has global aphasia. What action should the nurse take?
What is use the exact same words when repeating statements because the client may have only understood the first half of the sentence the first time and will need to have it repeated to understand the second half of the statement.
A nurse is caring for a patient who has a spinal cord injury. The nurse suspects that the client has autonomic dysreflexia. What should the nurse do first?
What is raise the head of the bed?
Using airway, breathing and circulation as your approach, the patient care is to immediately place the patient in a sitting position or raise the head of the bed to lower the patient’s blood pressure.
A nurse is reinforcing teaching with a family of a patient who is in a halo fixation device. What statement should the nurse make?
A nurse is collecting data from a patient who has an epidural hematoma. What manifestation should the nurse expect?
What is a lucid period followed by rapid loss of consciousness after the injury occurs because the patient who has an epidural hematoma will have a brief loss of consciousness followed by a lucid period. The lucid period is then followed by a rapid loss of consciousness and ultimately deteriorating to a coma.
What is small drops of clear fluid on the ear or nose which is most likely CSF indicating a risk for meningitis.
A nurse is collecting data from a patient following surgery for a brain tumor near the hypothalamus. Which finding would the nurse monitor the patient for because of the risks of surgery on this area of the brain?
What is the inability to regulate body temperature because the hypothalamus regulates body temperature in part.
A nurse is caring for a patient following a complete spinal cord transaction injury. The patient’s family asks the nurse what the term paraplegia means. The nurse responds how?
What is “he is unable to move his lower body and legs” typically resulting from injury to the lumbar spine.
A patient returns to the surgical unit from the PACU in skeletal traction. The nurse should take action to correct a problem with the weights. What problem could be occurring as it relates to the placement of the weights?
What is the weights resting against the foot of the bed or lying on the floor do not apply the proper traction essential for reducing the fracture and immobilizing the bone. They need to be hanging.
A nurse is caring for a patient who sustained a basilar skull fracture. When performing morning hygiene care, the nurse notices a thin stream of clear drainage coming from out of the patient’s right nostril and right ear. What should the nurse do first?
What is test the drainage for glucose because a CSF leak is this patient’s greatest risk due to the basilar skull fracture.
A nurse is collecting data from a patient who is 6 days post craniotomy for removal of an intracerebral aneurysm. The nurse should monitor the patient for which of the following manifestations of increased intracranial pressure?
What is Hypertension because this is an early manifestation of increased intracranial pressure.
A nurse is planning to perform passive range of motion for a patient who is immobilized. What action should the nurse take?
What is support the extremities above and below the joints to prevent muscle strain or injury.
A nurse is caring for a patient following major spinal surgery who is reporting pain. The patient’s partner tells the nurse “I wish I could do something to make my wife feel better” The nurse should respond how?
What is ”It must be difficult for you to see your wife in pain”.
A nurse is collecting data from a patient who has skeletal traction. What finding would the nurse identify as an indication of infection at the pin sites?
What is a fever. Inflammation and infection at the pin sites include fever, purulent drainage, odor, loose pins, and tenting of the skin around the pin sites.
A nurse is collecting data from a patient who has a traumatic head injury. What should the nurse report to the provider immediately?
What is sudden sleepiness which makes the patient unstable due to the increase in intracranial pressure.
A nurse is caring for a patient at risk for increased intracranial pressure and is monitoring them for manifestations that indicate that the pressure is increasing. To do this, the nurse must check the function of the third cranial nerve by performing which of the following?
What is checking the pupillary responses to light, because CN III, the oculomotor nerve, is responsible for pupillary responses to light. Changes to the pupils is one of the many indications that intracranial pressure is increasing such as a sluggish response to l iaht and dilation of one or both pupils.
A nurse is collecting data from a patient who was involved in a motor-vehicle crash. Which of the following techniques should the nurse use to test for corneal reflexes?
What is lightly touch the eye with a wisp of cotton because corneal reflexes result from the loss of the ability to blink due to a head injury or stroke. Normal would be blinking, corneal reflex abnormality would be the abnormal.
A nurse is contributing to the plan of care for a patient who has a spinal cord injury resulting in paraplegia. How should the nurse intervene?
What is provide a high-protein, high-calorie diet because this patient will have increased calorie needs.
A nurse is reinforcing teaching with a patient who has left Hemiparesis about how to use a cane. Which of the following instructions should the nurse include?
What is Hold the cane on the right side to provide support for the weaker leg meaning the patient will be holding the cane with the stronger hand.
A nurse is assisting with caring for a patient who has a new concussion following a motor vehicle crash. The nurse should monitor the patient for which of the following manifestations of increased intracranial pressure?
What is lethargy? Lethargy is an early manifestation of increased intracranial pressure.
A nurse is collecting data from a patient who has increased intracranial pressure and is informed by the charge nurse that the client demonstrates decorticate posturing. Which of the following findings should the nurse expect to observe?
What is plantar flexion of the legs, an indicator of decorticate posturing and a result of lesions on the spine.
A nurse is caring for a patient during the immediate postoperative period following thoracic surgery. When administering an opioid analgesic for pain, the nurse should explain that the medication should have which of the following effects?
What is reduce anxiety because opioids produce feelings of well-being.