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59 Cards in this Set
- Front
- Back
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What is meningitis?
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Meningitis is an inflammation of the meninges, which are the membranes that protect the brain and spinal cord
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What is viral meningitis?
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Viral or aseptic meningitis, is the most COMMON form
May be caused by VIRAL ILLNESSES such as the mumps, measles, herpes, and arboviruses such as the mosquito-borne West Nile Virus |
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What is bacterial meningitis?
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Bacterial or septic meningitis, is a CONTAGIOUS INFECTION WITH A HIGH MORTALITY RATE - the prognosis depends on how quickly care is initiated
Caused by BACTERIAL-BASED INFECTIONS, such as otitis media, pneumonia, or sinusitis, in which the infectious micro-organism is Neisseria meningitidis, Streptococcus pneumoniae or Haemophilus influenzae May also be caused by clients who are immunosuppressed, penetrating head wound (direct access to CSF) or clients who live in overcrowded or communal living conditions |
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What signs and symptoms would your client present with who may have meningitis?
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-Subjective-
Excruciating headache, that's constant Nuchal rigidity (stiff neck) Photophobia (sensitivity to light) -Objective- Fever and chills Nausea and vomiting Altered level of consciousness Disorientation to person, place and time Abnormal eye movements Positive KERNIG'S sign Positive BRUDZINKI'S sign Tachycardia Seizures Red, macular rash (meningitis) Alterations in motor function |
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Why would a lumbar puncture be done for clients who may have meningitis?
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Lumbar puncture for CSF analysis is the most DEFINITIVE diagnostic procedure
Appearance of CSF - cloudy (bacterial), clear (viral) |
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What are some nursing considerations for patients who have meningitis?
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ISOLATE CLIENT'S AS SOON AS MENINGITIS IS EXPECTED!
Maintain isolation precautions (DROPLET PRECAUTIONS) The nurse should wear a mask when standing within 3 ft of the client Decrease environmental stimuli (quiet environment, decrease light) Fever-reduction measures if necessary (cooling blanket) Maintain bed rest with HOB elevated to 30 degrees to reduce ICP pressure Maintain client safety, initiate seizure precautions |
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What type of medications would the patient who has meningitis be receiving?
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Ceftriaxone (Rocephin) or cefotaxime (Claforan): give antibiotics until C&S results are available
Phenytoin (Dilantin): anticonvulsants are given if ICP increases, or the client has a seizure Acetaminophen (Tylenol), ibuprofen (Motrin): analgesics are given for headache and/or fever - NON-OPIOID to avoid making changes in LOC Ciprofloxacin (Cipro) or rifampin (Rifadin): prophylactic antibiotics are given to individuals in close contact with the client |
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You are caring for a client with a diagnosis of bacterial meningitis, what would you want to include in your nursing care plan for the patient?
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Isolate client as soon as meningitis is suspected
Maintain droplet precautions Maintain bed rest with HOB elevated to 30 degrees to reduce ICP Administer medications as prescribed - assess neurological status |
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List come client education for clients who are risk for meningitis or who have been diagnosed with meningitis
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Encourage adults who are immunocompromised, who have a chronic disease, who smoke cigarettes, or who live in a long-term care facility to receive the pneumococcal polysaccharide vaccine (PPSV)
Encourage residential college students, older adults, and those who have a chronic illness to receive the meningococcal vaccine (MCV4) for Neisseria meningitidis Instruct clients to use an insect repellent when risk of being bitten by a mosquito exists |
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Scenario: A nurse is assisting an Rn admit a client who is diagnosed with bacterial meningitis from Neisseria meningitidis
Which of the following findings should the nurse expect? (Select all that apply) A) Fever B) Photophobia C) Vomiting D) Hemiparesis E) Bradycardia |
A) Fever
B) Photophobia C) Vomiting D) Hemiparesis E) Bradycardia *Fever, photophobia and vomiting are important signs of BACTERIAL MENINGITIS - decreased muscle tone, hemiparesis and hemiplegia may occur LATER in the course of the illness *TACHYCARDIA, NOT bradycardia is an expected finding in a client who has bacterial meningitis |
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What associated risk factors may the client report to the nurse when collecting data? (Select all that apply)
A) Residential living in a dormitory B) Current treatment of asthma with corticosteroids C) Report of being bitten by a tick D) History of otitis media E) History of multiple mosquito bites when camping |
A) Residential living in a dormitory
B) Current treatment of asthma with corticosteroids D) History of otitis media *Clients who live in a communal setting, such as dormitory, are at RISK for contracting bacterial meningitis if they have not been immunized - bacteria-based infections such as otitis media and sinusitis, as well as medications that can cause immunosuppression, such as corticosteroids, can place a client at risk for bacterial meningitis *Mosquito bites cause VIRAL, NOT bacterial meningitis |
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Which of the following isolation precautions should the nurse implement to prevent transmission of the disease?
A) Wear gloves when entering the client's room B) Place the client in a room with negative airflow exchange C) Wear a mask when standing at the bedside of the client D) Place a N-95 HEPA filter mask on the client when transmission outside the room occurs |
C) Wear a mask when standing at the bedside of the client
*DROPLET PRECAUTIONS are required for clients who have meningitis - when droplet precautions are required, a mask must be worn when within 3 feet of the client |
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A nurse is caring for a client with meningitis, which of the following findings during data collection should the nurse immediately report to the provider?
A) Fever B) Report of photophobia C) Duskiness of nail beds and fingers D) Restlessness |
C) Duskiness of nail beds and fingers
*Using airway, breathing, circulation (ABC) approach to client care, the priority finding is duskiness of the nail beds because this finding may indicate that septic emboli are compromising circulation of the extremities, which can cause gangrene in the fingers and toes |
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What is Parkinson's disease?
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Parkinson's disease (PD) is a PROGRESSIVELY DEBILITATING DISEASE that grossly affects motor function
Characterized by 4 primary symptoms (4 cardinal signs) 1. Tremors 2. Bradykinesia (slow movement) 3. Postural instability 4. Muscle rigidity |
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Explain the pathophysiology of Parkinson's disease
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The SECRETION of dopamine and acetylcholine in the body PRODUCE INHIBITORY and excitatory effects on the muscles respectively
In Parkinson's disease, OVERSTIMULATION OF THE BASAL GANGLIA by acetylcholine occurs because DEGENERATION of the substantia nigra results in DECREASED DOPAMINE PRODUCTION - this allows ACETYLCHOLINE TO DOMINATE, making smooth, controlled movements difficult |
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What are the signs and symptoms of Parkinson's disease?
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Stooped posture
Slow, shuffling, and propulsive gait Slow, monotonous speech Tremors, pill-rolling tremor of he fingers Muscle rigidity Bradykinesia/akinesia Mask-like facial expression Drooling Dysarthria Progressive difficulty performing ADL's |
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What are some important nursing interventions for patients who have Parkinson's disease?
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Administer client's medication at prescribed times
Monitor swallowing and maintain adequate nutrition Request referral for a speech-language pathologist to assess swallowing if clients demonstrate a risk for choking Provide, smaller, more frequent meals Add commercial thickener to foods Maintain client mobility as long as possible Encourage ROM exercises Assist clients with ADL's as needed (hygiene, dressing) Promote communication for as long as possible (instruct client to do facial muscle strengthening exercises) Monitor the client's mental and cognitive status (observe for signs of depression and dementia) Provide a SAFE ENVIRONMENT (NO throw rugs, encourage the use of an electric razor) |
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What type of medications may be used in the treatment of a patient with Parkinson's?
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-Dopaminergics-
When given orally, medications such as LEVODOPA (DOPAR) are converted into dopamine in the brain, INCREASING DOPAMINE LEVELS in the basal ganglia Dopaminergics may be combined with carbidopa (SINEMET) to decrease peripheral metabolism of levodopa, requiring a smaller dose to make the same amount available to the brain Due to medication tolerance and metabolism, client's dosage may need to be adjusted to avoid periods of poor mobility Side effects: nausea/vomiting, dyskinesias (head bobbing, grimacing, tremors), orthostatic hypotension, tachycardia, palpitations, psychosis (visual hallucinations), discoloration of sweat and urine **Monitor for the "wearing off", phenomenon and dyskinesias (problems with movement), which can indicate a need to adjust the dosage or call for a "medication holiday" **Proteins interfere with levodopa absorption and transport across the blood-brain barrier - high protein meals DECREASE THERAPEUTIC EFFECTS** |
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What type of medications may be used in the treatment of Parkinson's?
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-Dopamine agonists-
Such as bromocriptine (PARLODEL) and pramipexole (MIRAPEX), ACTIVATE THE RELEASE OF DOPAMINE - may be used in conjunction with a dopaminergic for better results Side effects: sudden ability to stay awake, daytime sleepiness, orthostatic hypotension, psychosis (visual hallucinations), dyskinesias (head bobbing, tics, tremors), nausea |
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What type of medications may be used in the treatment of Parkinson's?
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-Anticholinergics-
Such as benztropine (Cogentin) and trihexyphenidyl (Artane), help control tremors and rigidity Side effects: nausea and vomiting (advise clients to take medication with food, but to AVOID HIGH PROTEIN SNACKS), monitor for ANTICHOLINERGIC EFFECTS (blurred vision, urinary hesitancy or retention or constipation), antihistamine effects (sedation, drowsiness) **Client should be alert for dry mouth, difficulty urinating, constipation** |
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What type of medications may be used in the treatment of Parkinson's?
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-Antivirals-
Such as amantidine (Symmetrel), stimulate the release of dopamine and prevent its reuptake Side effects: CNS effects (confusion), anticholinergic effects, discoloration of skin, client should monitor for swollen ankles and discoloration of the skin |
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What are some complications of Parkinson's disease?
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Aspiration pneumonia: as PD advances in severity, alterations in chewing and swallowing will WORSEN, increasing the RISK for aspiration
Nursing actions: use swallowing precautions, encourage clients to chew thoroughly before swallowing, feed clients in an UPRIGHT position, have suction equipment ready |
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Scenario: An older adult client was diagnosed with Parkinson's 1 year ago. He is currently living independently with his wife of 50 years and takes levodopa with carbidopa (SINEMET) to control his disease. Due to a recent episode of aspiration pneumonia, the client has been admitted to the hospital for IV antibiotics and respiratory therapies.
Which of the following findings should the nurse expect to find when collecting data? (Select all that apply) A) Decreased vision B) Pill-rolling tremor of the fingers C) Shuffling gait D) High-pitched, squeaky voice E) Lack of facial expressions F) Frequent periods of sleep |
B) Pill-rolling tremor of the fingers
C) Shuffling gait E) Lack of facial expressions *Clients with PD will experience pill-rolling tremor of the fingers, shuffling gait and lack of facial expressions - LACK of sleep, rather than frequent periods of sleep are experienced |
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Which of the following questions should the nurse ask to determine if the medication is being given in appropriate dosages and at the appropriate times?
A) "Is your weight staying the same?" B) "Can you see the television from a comfortable distance?" C) "Are you having periods when walking is more difficult?" D) "Are you experiencing any night sweats?" |
C) "Are you having periods when walking is more difficult?"
*Increased difficulty walking may indicate the client is having periods when the medication is "wearing off", and adjustment of the dosage is indicated |
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Which of the following is the priority intervention the nurse should recommend for inclusion on the client's plan of care?
A) Assist the client to the restroom B) Have assistive personnel assist the client with dressing C) Have suction equipment ready D) Observe IV catheter insertion site for inflammation every 12 hours |
C) Have suction equipment at bedside
*Using airway, breathing, circulation priority setting framework, suction equipment should be placed at the client's bedside due to the continued risk for aspiration and subsequent airway obstruction |
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The client has been prescribed bromocriptine (PARLODEL) to obtain better management of the muscular rigidity - which of the following instructions should the nurse give the client to manage a common side effect of bromocriptine (PARLODEL)?
A) Rise slowly when standing up B) Increase dietary fiber and fluid intake C) Chew sugarless gum for dry mouth D) Wear sunscreen when outdoors |
A) Rise slowly when standing up
*Orthostatic hypotension is a common side effect of bromocriptine (PARLODEL) - rising slowly will decrease the risk of dizziness and lightheadedness |
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What is Alzheimer's disease?
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AD is a NONREVERSIBLE TYPE OF DEMENTIA (multiple cognitive deficits that impair memory and can affect language, motor skills, and/or abstract thinking) that PROGRESSIVELY DEVELOPS through stages over many years
Severe physical decline occurs along with deteriorating cognitive function |
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What are some risk factors for Alzheimer's disease?
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Advanced age
Genetic predisposition Environmental agents (herpes, metal or toxic wastes) Previous head injury Apolioprotein E |
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What are the 7 stages of Alzeheimer's disease?
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Stage 1: no impairment - normal function
Stage 2: very mild cognitive decline - forgetfulness of everyday objects Stage 3: mild cognitive decline - losing or misplacing common objects, short-term memory loss Stage 4: moderate cognitive decline - personality changes (withdrawn), obvious memory loss, limited knowledge and memory of recent occasions Stage 5: moderately severe cognitive decline - increasing cognitive deficits emerge, disorientation and confusion to time and place Stage 6: severe cognitive decline - memory difficulties continue to worsen, loss of awareness, wandering behavior Stage 7: very severe cognitive decline - ability to respond to environment, speak and control movement is lost |
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You have a client who has Alzhemier's and you are doing a teaching plan for home care, the client is in the late stages of AD and is wondering and disoriented, what should you include?
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Remove throw rugs
Good lighting in hallways Put handrails in the bathroom Place mattress on the floor (if patient rolls out of bed) |
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What are some nursing interventions for the client with AD?
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Check cognitive status, memory, judgement and personality changes
Initiate bladder and bowel program with clients based on a set schedule Provide a SAFE environment Provide cognitive stimulation (calendar for orientation, be consistent or repetitive, offer various environmental stimulations such as walks, music or crafts) Provide memory training (reminisce with clients about the past, use memory techniques) Promote self care for as long as possible Reduce agitation, don't argue with the client |
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What type of medications may be used for AD patients?
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AD medications temporarily SLOW the course of the disease but do not work for all clients
Benefits for those clients who do respond t the medication include improvements in cognition, behavior and function DONEPEZIL (ARICEPT): prevents the breakdown of acteylcholine, which INCREASES THE AMOUNT OF ACETYLCHOLINE AVAILABLE, this results in increased nerve impulses at the nerve sites Cholinesterase inhibitors help slow this process down Nursing considerations: observe clients for FREQUENT STOOLS and/or upset stomach, monitor clients for dizziness and headache (clients may have an unsteady gait) |
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What are some nursing interventions and care to teach the family for home care of an AD patient?
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Instruct families in home safety measures
Remove scatter rugs Place mattress on the floor Provide good lighting Place handrails in the bathroom Remove clutter |
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A family member of a client who has Alzheimer's disease asks the nurse about risk factors for AD, the nurse should inform the family member that which of the following are risk factors for AD? (Select all that apply)
A) Age B) Family history C) Smoking D) Sun exposure E) Previous head injury |
A) Age
B) Family history E) Previous head injury *Age, family history and previous head injury are risk factors for AD |
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A nurse is reinforcing teaching to an older client who has AD and his wife. The client has been prescribed donepezil (Aricept). Which of the following statements by his wife indicates an understanding of the teaching about the medication? (Select all that apply)
A) "It should be taken in the morning before breakfast" B) " It should increase my husbands appetite" C) "It should help my husband sleep better" D) "It may cause diarrhea" E) "It should help my husband's daily function" |
D) "It may cause diarrhea"
E) "It should help my husband's daily function" *Donepezil (Aricept) may cause diarrhea to its cholinergic effects - it helps to slow down the progression of AD - it can also help improve behavior and daily functioning |
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A nurse is caring for a client with AD. The client needs assistance with dressing and grooming, this manifestation represents which of the following stages of AD?
A) Stage 3 B) Stage 4 C) Stage 5 D) Stage 6 |
D) Stage 6
*In stage 6 of AD, the client may have difficulty with ADL's, including dressing and grooming |
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What is a CVA?
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CVA = cerebral vascular accident, aka "stroke". Involves the disruption in the cerebral blood flow secondary to ischemia, hemorrhage or embolism
There are 3 types of CVA's: 1. Hemorrhagic: cranial bleed 2. Thrombotic: blood lot 3. Embolic: traveling blood clot |
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What are the risk factors for a CVA?
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CEREBRAL ANEURYSM
Arteriovenous malformation Diabetes Mellitus Obesity HYPERTENSION Atherosclerosis Hyperlipidemia Hypercoagulability Atrial fibrillation Use of oral contraceptives Smoking Cocaine use |
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What are the signs and symptoms of a CVA?
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-Subjective-
Some clients report transient symptoms such as dizziness, slurred speech and a weak extremity These symptoms may indicate a TIA (TRANSIENT ISCHEMIC ATTACK), which can be a WARNING SIGN of an impending CVA -Objective Data- Symptoms will vary based on the area of the brain that is deprived of blood LEFT CEREBRAL HEMISPHERE - responsible for language, mathematics, and analytic thinking -symptoms: Expressive and receptive aphasia Agnosia (unable to recognize familiar objects) Alexia (reading difficulty) Agraphia (writing difficulty) RIGHT EXTREMITY HEMIPLEGIA (PARALYSIS) OR HEMIPARESIS (WEAKNESS) Visual changes such as hemianopsia (loss of visual field in one or both eyes) One-sided neglect syndrome (ignore R side of the body) - cannot see, feel, or move affected side |
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What are the signs and symptoms of a CVA?
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RIGHT CEREBRAL HEMISPHERE- responsible for visual and spatial awareness and proprioception - symptoms:
Altered perception deficits (overstimulation of abilities) One-sided neglect syndrome (ignore L side of the body) Loss of depth perception Poor impulse control and impaired judgement Visual changes such as hemianopsia |
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What are some nursing considerations for clients who have experienced a CVA?
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Monitor for changes in the client's LOC (decreased LOC is a sign of ICP)
Elevate HOB to 30 degrees to reduce ICP, avoid extreme flexion of the neck Initiate seizure precautions Assist with the client's communication if speech is impaired Assist with safe feeding (check swallowing and gag reflexes before feeding - follow recommendations of speech pathologist) Thicken clear liquids with a commercial thickener to avoid aspiration Have clients eat in an upright position and swallow with the head flexed slightly forward Place food in the back of mouth on the unaffected side Have suction on standby Maintain skin integrity Maintain SAFE ENVIRONMENT If client's have one-sided neglect, teach them to care and protect the affected extremity |
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What type of medications may be administered for client's who have had a CVA?
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-Anticoagulants-
Aspirin, Heparin, Lovenox, Coumadin These medications are given to clients who have experienced an embolic CVA to PREVENT development of ADDITIONAL EMBOLI -Antiplatelets- Clopidogrel (PLAVIX) Usually given to clients who have experienced a thrombotic CVA to prevent EXTENSION of the CVA -Thrombolytic- Altepase Can be given within 3-6 hours of onset of symptoms to DISSOLVE the embolism (clot buster!) -Antiepileptic- Phenytoin (Dilantin), gabapentin (Neurontin) These medications are NOT commonly given after a CVA, UNLESS client develops seizures Gabapentin can be given for neuropathic pain in an extremity |
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What is a carotid endarterectomy?
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Performed to open the artery by removing atherosclerotic plaque - this procedure is performed when the carotid artery is blocked or when clients are experiencing TIA's
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What are some complications of a CVA?
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Dysphagia and aspiration: dysphagia can result from neurological impairment of the cranial nerves that innervate the face, tongue, soft palate, and throat - as a result, client's risk for aspiration is great
*Thicken oral liquids as prescribed, have suction equipment on standyby Unilateral neglect: loss of awareness of the side affected by the CVA - clients cannot see, feel, or move affected side - therefore they forget it exists This lack of awareness poses a great risk for injury to the neglected extremity and creates a self care deficit **Instruct client's to dress the affected side first** |
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A nurse in a long term care facility is collecting data from an older client who is being observed for a transient ischemic attack (TIA), which of the following are manifestations of a TIA? (Select all that apply)
A) Unilateral numbness of the arm B) Stiff neck C) Dizziness D) Slurred speech E) Otorrhea |
A ) Unilateral numbness of the arm
C) Dizziness D) Slurred speech *Weakness or numbness of one side of the body, dizziness and slurred speech are indications that the client may be experiencing a TIA, these symptoms usually resolve over few minutes to hours during a TIA |
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The nurse is caring for a client who has been diagnosed with left homonymous hemianopsia. Which of the following actions by the nurse is appropriate?
A) Tell the client to scan to the right to see objects on the right side of the body B) Place the client's bedside table on the right side of the bed C) Orient the client to food on a plate using the clock method D) Place the client's wheelchair on his left side |
B) Place the client's bedside table on the right side of the bed
*Client with left homonymous hemianopsia has lost left visual field of both eyes, placing the client's bedside table on the right side of his bed will allow him to easily visualize items on the table |
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A nurse is caring for a client who is recovering from a stroke and needs assistance with eating. Which of the following actions should the nurse take? (Select all that apply)
A) Have suction equipment available for use B) Thicken liquids using commercial thickener C) Place food on unaffected side of the mouth D) Instruct client to swallow with his neck flexed E) Discontinue feeding the client if choking occurs |
A) Have suction equipment available for use
B) Thicken liquids using commercial thickener C) Place food on unaffected side of the mouth E) Discontinue the feeding if choking occurs |
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A nurse has been assigned a client who has been diagnosed with global aphasia (both receptive and expressive). Which of the following interventions are appropriate to include in the client's plan of care? (Select all that apply)
A) Speak to the client at a slower rate B) Look directly at the client when speaking C) Allow plenty of time for the client to answer D) Complete sentences the client cannot finish E) Break tasks into parts and give instructions one step at a time F) Speak louder if the client does not understand |
A) Speak to the client at a slower rate
B) Look directly at the client when speaking C) Allow plenty of time for the client to answer E) Break tasks into parts and give instructions one step at a time *Clients with global aphasia will have difficulty with both speaking and understanding speech |
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What is a spinal cord injury?
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Spinal cord injuries (SCI's) involve the loss of motor function, sensory function, reflexes and control of elimination - injuries in the cervical region result in quadriplegia - paralysis/paresis of all 4 extremities and trunk - injuries below T1 result in paraplegia/paralysis of the lower extremities
*Incomplete lesions result in varying losses of voluntary movement, and sensation below the level of injury |
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What are the signs and symptoms of a spinal cord injury?
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-Subjective-
Report of lack of sensation of dermatones below the level of the lesion Report of neck or back pain -Objective- Inability to feel light touch when touched by a cotton ball, inability to discriminate between sharp and dull when touched with a safety pin or other sharp objects, and an inability to discriminate between hot and cold Absent deep-tendon reflexes Involuntary respirations can be affected due to a lesion at or above the phrenic nerve, or swelling rom a lesion immediately below C4 SPINAL SHOCK - which accompanies spinal trauma, causes a TOTAL LOSS OF ALL REFLEX AND AUTONOMIC FUNCTION BELOW THE LEVEL OF INJURY FOR A PERIOD OF SEVERAL DAYS TO WEEKS Clients who have upper motor neuron injuries will develop a spastic bladder after the spinal shock resolves Clients who have lower motor neuron injuries will develop a flaccid bladder |
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What are some nursing interventions for the client with a SCI?
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MAINTAIN RESPIRATORY FUNCTION!
Monitor the client's respiratory status Maintain tissue perfusion Monitor changes in neurological function Monitor client's for changes in muscle strength in the affected extremities SPASTIC NEUROGENIC BLADDER: for male clients, include condom catheters, females will use an indwelling catheter FLACCID: males intermittent catheterization and Crede' method |
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What are some medications that may be used for an SCI?
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-Glucocorticoids-
Adrenocortical steroids such as dexamethasone (DECADRON) aid in decreasing swelling of the spinal cord, which can increase pressure on the spinal cord, and subsequently areas of ischemia -Vasopressors- Norepinepherine and dopamine are given to treat postural hypotension, particularly during a spinal shock -Muscle Relaxants- Baclofen (Lioresal) and dantrolene sodium (Dantrium), given to clients who have severe muscle spasticity -Cholinergics- Bethanechol (Urecholine), decreases spasticity of the bladder allowing for easier bladder training and fewer accidents *Observe client's for urinary retention, constipation, dry mouth -Anticoagulants- Heparin, used for DVT prophylaxis *Observe for signs of GI bleeding -Stool Softeners- Docusate sodium (Colace) to prevent constipation |
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What is neurogenic shock?
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Neurogenic shock is a common response of the spinal cord following an injury
Symptoms include: bradycardia, hypotension, flaccid paralysis, loss of reflex activity below the level of injury, and paralytic ileus accompany spinal shock due to the loss of autonomic function |
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What is autonomic dysreflexia?
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Occurs secondary to the stimulation of the sympathetic nervous system and inadequate compensatory response by the parasympathetic nervous system
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What are the nursing actions for the client with autonomic dysreflexia?
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Determine and treat the cause!
SIT CLIENTS UP IN BED (TO DECREASE BLOOD PRESSURE SECONDARY TO POSTURAL HYPOTENSION) Distended bladder is the most common cause (kinked catheter or blocked urinary catheter, urinary retention, urinary calculi) Fecal impaction Tight clothing Cold stress or drafts on lower part of the body |
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Scenario: A nurse is caring for a male client in a rehabilitation facility who has a spinal cord injury at C6. His fracture was treated with anterior fusion between levels C5 to C7, he is now receiving therapy to increase his mobility and ability to preform ADL's
Upon review of the clients chart, the nurse notes that the client received methylprednisone (Sol-Medrol) when he was initially treated for the cervical injury. The purpose of this medication at the time was to... A) Decrease swelling in the spinal cord B) Control muscle spasticity C) Prevent bradycardia D) Expand blood volume |
A) Decrease swelling in the spinal cord
*Clients who have an SCI may be given corticosteroids such as methylprednisone in the first few hours after the injury to decrease inflammation of the spinal cord, thereby preventing further damage due to pressure caused by swelling of the spinal cord, thereby preventing further damage caused by swelling |
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After drinking a large amount of fluid, the client reports a severe headache, and is found to be sweating profusely. The client's BP is 210/110, and his HR is 54/min, which of the following actions should the nurse take first?
A) Call the provider B) Sit the client upright in bed C) Check the client's bladder for distention D) Administer an antihypertensive |
B) Sit the client up in bed
*The client is exhibiting signs of autonomic dysreflexia. The greatest risk is experiencing a stroke secondary to the dangerously high BP - therefore the FIRST action the nurse should take is to elevate the head of the bed until the client is in upright position - this will naturally lower the BP secondary to postural hypotension |
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Which of the following are other stimuli that could cause the client to experience autonomic dysreflexia? (Select all that apply)
A) Kidney stone B) Fecal impaction C) Metabolic acidosis D) Pulmonary embolism E) Pressure ulcer |
A) Kidney stone
B) Fecal impaction E) Pressure ulcer *Autonomic dysreflexia is an emergency situation that occurs from hyperactivity of the autonomic nervous system secondary to the source of stimulus in the lower part of the body |
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Which of the following types of bladder management methods is appropriate for this client?
A) Condom catheter B) Intermittent catheterization C) Crede' D) Indwelling catheter |
A) Condom catheter
*A client with a CERVICAL injury will have an upper motor neuron injury, which will manifest itself by creating a spastic bladder once spinal shock resolves *Since the spastic bladder will empty on its own, a condom catheter is an appropriate bladder management method, it is NONINVASIVE as opposed to an indwelling catheter |
