Which patient should be assigned to the traveling nurse, new to neurologic nursing care, who has been on the neurologic unit for 1 week?
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Solution
A 68-year-old patient with chronic amyotrophic lateral sclerosis (ALS)
Option B: The traveling is relatively new to neurologic nursing and should be assigned patients whose conditions are stable and not complex. The newly diagnosed patient will need to be transferred to the ICU. The patient with C4 SCI is at risk for respiratory arrest.
Options A, C, and D: All three of these patients should be assigned to nurses experienced in neurologic nursing care. Focus: Assignment
You are preparing a nursing care plan for the patient with SCI including the nursing diagnosis Impaired Physical Mobility and Self-Care Deficit. The patient tells you, “I don’t know why we’re doing all this. My life’s over.” What additional nursing diagnosis takes priority based on this statement?
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Solution
Impaired Adjustment to Spinal Cord Injury
Option C: The patient’s statement indicates impairment of adjustment to the limitations of the injury and indicates the need for additional counseling, teaching, and support.
Options A, B, and D: The other three nursing diagnoses may be appropriate to the patient with SCI, but they are not related to the patient’s statement. Focus: Prioritization
The patient with a cervical SCI has been placed in fixed skeletal traction with a halo fixation device. When caring for this patient the nurse may delegate which action (s) to the LPN/LVN? (Choose all that apply).
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Solution
Answers: A, C, and D
Options A, C, and D: Checking and observing for signs of pressure or infection are within the scope of practice of the LPN/LVN. The LPN/LVN also has the appropriate skills for cleaning the halo insertion sites with hydrogen peroxide.
Option B: Neurologic examination requires additional education and skill appropriate to the professional RN. Focus: Delegation/supervision
You are helping the patient with an SCI to establish a bladder-retraining program. What strategies may stimulate the patient to void? (Choose all that apply).
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Solution
Answers: A, B, D, and E
Options A, B, D, and E: All of the strategies, except straight catheterization, may stimulate voiding in patients with SCI.
Option C: Intermittent bladder catheterization can be used to empty the patient’s bladder, but it will not stimulate voiding. Focus: Prioritization
You are pulled from the ED to the neurologic floor. Which action should you delegate to the nursing assistant when providing nursing care for a patient with SCI?
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Solution
Monitor respiratory effort and oxygen saturation level.
Option D: The first priority for the patient with an SCI is assessing respiratory patterns and ensuring an adequate airway. The patient with a high cervical injury is at risk for respiratory compromise because the spinal nerves (C3 – 5) innervate the phrenic nerve, which controls the diaphragm.
Options A, B, and C: The other assessments are also necessary, but not as high priority. Focus: Prioritization
A patient with a spinal cord injury at level C3-4 is being cared for in the ED. What is the priority assessment?
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Solution
A 67-year-old patient with stroke 3 days ago and left-sided weakness
Option B: The new graduate RN who is oriented to the unit should be assigned stable, non-complex patients, such as the patient with stroke.
Option D: The patient with Parkinson’s disease needs assistance with bathing, which is best delegated to the nursing assistant.
Option A: The patient being transferred to the nursing home and the newly admitted SCI should be assigned to experienced nurses. Focus: Assignment
Which patient should you, as charge nurse, assign to a new graduate RN who is orienting to the neurologic unit?
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Solution
Check the Foley tubing for kinks or obstruction.
Option B: These signs and symptoms are characteristic of autonomic dysreflexia, a neurologic emergency that must be promptly treated to prevent a hypertensive stroke. The cause of this syndrome is noxious stimuli, most often a distended bladder or constipation, so checking for poor catheter drainage, bladder distention, or fecal impaction is the first action that should be taken.
Option C: Adjusting the room temperature may be helpful, since too cool a temperature in the room may contribute to the problem.
Option A: Tylenol will not decrease the autonomic dysreflexia that is causing the patient’s headache.
Option D: Notification of the physician may be necessary if nursing actions do not resolve symptoms. Focus: Prioritization
A patient with a spinal cord injury (SCI) complains about a severe throbbing headache that suddenly started a short time ago. Assessment of the patient reveals increased blood pressure (168/94) and decreased heart rate (48/minute), diaphoresis, and flushing of the face and neck. What action should you take first?
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Solution
“I will avoid exercise because the pain gets worse.”
Option A: Exercises are used to strengthen the back, relieve pressure on compressed nerves and protect the back from re-injury.
Options B and D: Ice, heat, and firm mattresses are appropriate interventions for back pain.
Option C: People with chronic back pain should avoid wearing high-heeled shoes at all times. Focus: Prioritization
The nurse is preparing to discharge a patient with chronic low back pain. Which statement by the patient indicates that additional teaching is necessary?
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Solution
The NA performs the patient’s complete bath and oral care.
Option C: The nursing assistant should assist the patient with morning care as needed, but the goal is to keep this patient as independent and mobile as possible.
Options A, B, and D: Assisting the patient to ambulate, reminding the patient not to look at his feet (to prevent falls), and encouraging the patient to feed himself are all appropriate to goal of maintaining independence. Focus: Delegation/supervision
A patient with Parkinson’s disease has a nursing diagnosis of Impaired Physical Mobility related to neuromuscular impairment. You observe a nursing assistant performing all of these actions. For which action must you intervene?
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Solution
“It’s OK to take over-the-counter medications.”
Option D: A patient with a seizure disorder should not take over-the-counter medications without consulting with the physician first.
Options A, B, and C: The other three statements are appropriate teaching points for patients with seizures disorders and their families. Focus: Delegation/supervision