Spinal Cord Injury Next-Gen NCLEX Practice

Spinal Cord Injury Next-Gen NCLEX Practice Thinking Exercise 20-1 The nurse collaborates with the trauma team to admit and stabilize a 17-year-old male adolescent following a diving accident. According to the report from the emergency transport services, the client was at a lake with family and friends when he dove into the lake from the side of the boat but did not resurface. A family member rescued the adolescent from the water and began cardiopulmonary resuscitation. The client was intubated en route and presents now for stabilization. The nurse collects the following assessment data for the client: Temperature = 97.6 F Heart rate = 72 bpm and irregular Respiratory rate = 16 breaths/min. as set on ventilator, with no breathing over ventilator rate noted Oxygen saturation = 99% on 20% FiO2 Glasgow Coma Scale (GCS) score = 14 due to intubation Lung sounds = coarse with rhonchi in lower lobes bilaterally FLACC score = 3 Large abrasion on top of head Responds to commands Voluntary movements in upper extremities No movements noted in lower extremities bilaterally Initial CT scan of the spinal column demonstrates a severe and complete compression injury at the 10th thoracic vertebrae (T10) Based on the assessment findings, what priority actions would the nurse take to help stabilize the client at this time? Select all that apply. X X X X A. B. C. D. E. F. G. H. Use the log-roll method of repositioning and turning. Maintain endotracheal tube and manage the ventilator. Maintain a neutral thermal body temperature. Administer antibiotics as prescribed for a urinary tract infection. Perform neurologic checks every hour. Obtain health history and details of the accidental injury from family. Administer saline bolus as prescribed. Perform a thorough assessment of the scalp abrasion. Thinking Exercise 20-2 Choose the most likely options for the information missing from the statements below by selecting from the lists of options provided. The nurse recognizes that clients with spinal cord injury suffer both PHYSIOLOGICALLY and PSYCHOLOGICALLY this client are to STABALZE . The priority desired outcomes of treatment for the injury and prevent SECONDARY outcomes damage to his spinal cord. Additional client include establishing a BOWEL outcomes include and BLADDER maintaining the greatest amount of 4 as possible, monitoring the client’s adaptation to his paralysis, and preventing Options for 1 Physiologically Options for 2 Primary Options for 3 Sleep Mental breakdowns Rhabdomyolysis Psychologically Decrease Bowel Stabilize Tertiary Acute kidney injury Chronically Reduce Rest Physical therapy Bladder Secondary Occupational therapy regimen. Other PRESSURE INJURIES . Options for 4 Options for 5 Respiratory Metabolic acidosis effort Cardiac function Relapse Integrity Mobility Psychological integrity Sensory perception Pressure injury Acute kidney injury Bladder spasms Rhabdomyolysis Thinking Exercise 20-3 The nurse is developing a plan of care for a 17-year-old who was admitted to the hospital following a complete severing of the spinal cord at T10 resulting in paraplegia and necessitating mechanical ventilation for 24 hours; the client is now off the ventilator and breathing on his own. He was admitted to the neurosurgical unit after open reduction and internal fixation (ORIF) to stabilize his spine. Use an X to indicate whether the nursing actions below are Anticipated (appropriate or likely necessary), Contraindicated (could be harmful), or Non-Essential (make no difference or are not necessary) for the client’s postoperative care at this time. Nursing Actions Anticipated Monitor vital signs per facility standards X Encourage coughing and deep breathing exercises X Administer analgesic as prescribed X Reposition the client every 4 hours Apply sequential compression devices Contraindicate d NonEssential X X Keep NPO until client voids and reports no nausea X Obtain a prescription for echocardiogram X Consult clergy or social worker for family support X Collaborate with respiratory therapy to maintain oxygenation as needed X Complete a dietary assessment X Obtain a prescription for an indwelling urinary catheter X Monitor the client’s level of sensory perception every 4 hours X Collaborate with physical therapy to promote independence X