ATI LPN
Lewis's Medical Surgical Nursing in Canada, 5th Edition
Chapter 63 Questions
Question 1 of 5
The nurse is caring for a patient with a T2 spinal cord injury who tells the nurse, 'I feel awful today. My head is throbbing, and I feel sick to my stomach.' Which of the following actions should the nurse take first?
Correct Answer: C
Rationale: The BP should be assessed immediately in a patient with an injury at the T6 level or higher who complains of a headache to determine whether autonomic dysreflexia is occurring. Notification of the patient's health care provider is appropriate after the BP is obtained. Administration of an antiemetic is indicated after autonomic dysreflexia is ruled out as the cause of the nausea. The nurse may assess for a fecal impaction, but this should be done after checking the BP and lidocaine jelly should be used when performing a digital rectal exam to prevent further symptoms such as increases in the BP.
Question 2 of 5
The nurse is caring for a patient who has an incomplete right spinal cord lesion at the level of T7, resulting in Brown-Séquard syndrome. Which of the following nursing actions should be included in the plan of care?
Correct Answer: C
Rationale: The patient with Brown-Séquard syndrome has loss of motor function on the ipsilateral side and will require the nurse to move the right leg. Pain sensation will be lost on the patient's left leg. Left arm weakness will not be a problem for a patient with a T7 injury. The patient will retain position sense for the left leg.
Question 3 of 5
The nurse is caring for a patient who had a C8 spinal cord injury 10 days ago and has a weak cough effort and loose-sounding secretions. Which of the following actions should the nurse implement initially?
Correct Answer: C
Rationale: Since the cough effort is poor, the initial action should be to use assisted coughing techniques to improve the ability to mobilize secretions. The nurse places the heels of both hands just below the patient's xiphoid process and exerts firm upward pressure to the area, timed with the patient's efforts to cough. Administration of oxygen will improve oxygenation, but the data do not indicate hypoxemia. The use of the spirometer may improve respiratory status, but the patient's ability to take deep breaths is limited by the loss of intercostal muscle function. Suctioning may be needed if the patient is unable to expel secretions by coughing but should not be the nurse's first action.
Question 4 of 5
The nurse is caring for a young adult patient with a T3 spinal cord injury who asks the nurse about whether he will be able to be sexually active. Which of the following initial responses by the nurse is best?
Correct Answer: C
Rationale: Although sexuality will be changed by the patient's spinal cord injury, there are options for expression of sexuality and for fertility. The other information also is correct, but the choices will depend on the degrees of injury and the patient's individual feelings about sexuality.
Question 5 of 5
The nurse is caring for a patient with Bell's palsy who refuses to eat while others are present because of embarrassment about drooling. Which of the following responses is best for the nurse to do?
Correct Answer: A
Rationale: The patient's desire for privacy should be respected to encourage adequate nutrition and reduce patient embarrassment. Liquid supplements will reduce the patient's enjoyment of the taste of food. It would be inappropriate for the nurse to discuss the patient's embarrassment with visitors unless the patient wishes to share this information. Chewing on the unaffected side of the mouth will enhance nutrition and enjoyment of food but will not decrease the drooling.