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This activity contains 10 questions.
A client has sustained an injury to the mid-sacral region of his spinal cord. The nurse realizes this client might experience an alteration in:
A client who was in a motor vehicle accident a few days ago is now complaining of progressive weakness in his arms and upper body while the functioning of his lower limbs is unchanged. Which of the following might this client be experiencing?
Anterior cord syndrome
Central cord syndrome
A client with a spinal cord injury asks the nurse how much permanent damage will he have. The nurse replies:
Because of swelling, it might take a few days before we can evaluate that.
Don't worry. Functioning will return.
What are you able to do now?
I don't think you will get much better than you are now.
The nurse is caring for a client demonstrating spinal shock. What should be included in the plan of care for this client?
Provide triple H therapy.
Monitor intake and output.
Report changes in blood pressure.
Provide oral fluids.
Provide vasodilator medications as prescribed.
Support paralyzed extremities.
The nurse is preparing a plan of care for a client in a halo vest. What should be included?
Loosen pins if client complains of pain.
Use the vest to help move the client in bed.
Remove the vest for bathing.
Tape a halo vest wrench on the front of the vest.
Assess skin around the vest daily.
Perform pin care.
A client with a cervical spinal cord injury is demonstrating ineffective airway maintenance. Which of the following can the nurse do to help this client?
Provide laxatives as prescribed by physician.
Perform chest physiotherapy and postural drainage every 2-4 hours.
Provide vasopressors per physician's order.
Keep atropine at the bedside.
Insert indwelling urinary catheter.
Teach quad coughing technique.
A client with a cervical spinal cord injury is being started on a bowel care program. Which of the following should be included in this client's plan of care?
Teach client to do the Valsalva maneuver to initiate defecation.
Keep client on a fluid restriction.
Obtain orders from the physician for laxatives and stool softeners.
Instruct family to stimulate the anal-rectal reflex to initiate defecation.
Place a consult for a dietitian to instruct the client in high-fiber foods.
Place client on bed pan every 2 hours.
A client with a spinal cord injury is exhibiting poikilothermia. Which of the following would be appropriate to include in this client's plan of care?
Keep client warm with extra blankets.
Provide good perineal care.
Stimulate the anal-rectal reflex.
Pass nasogastric tube to decompress stomach.
A client with a spinal cord injury is exhibiting an area of red skin on the sacral area. What can be done to help this client?
Keep skin moist.
Turn and reposition the client every 2 hours and prn.
Apply elastic stockings.
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A client is exhibiting status epilepticus. What are the two goals of care for this client?
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