HESI Spinal Cord Injury. | Exams Nursing

HESI Spinal Cord Injury

What should Jonathan's friends do while waiting for emergency personnel to arrive

(select all that apply)

A) help Jonathan move his legs and assist him to sit up

B) place a blanket over Jonathan and make sure no one moves him

C) attempt to stabilize his neck with any type of soft material

D) carefully put Jonathan in the back of a truck with one man holding his neck

E) ensure that the scene around Jonathan is safe and that he's not in any immediate

danger - ✅B) place a blanket over Jonathan and make sure no one moves him .

any movement or improper handling could cause further damage and loss of

neurological function

E) ensure that the scene around Jonathan is safe and that he is not in any immediate

danger. Ensuring that the scene is safe and protecting Jonathan from any immediate

danger is important

If respiratory compromise occurs what action should the RN take to keep the airway

open without compromising Jonathan's spine further?

A) Logroll to side while maintaining neutral alignment

B)perform the jaw-thrust technique

C)flex the neck with a wedge pillow

D)use the chin-lift/head tilt technique - ✅B) perform the jaw-thrust technique. The jaw-

thrust is the safest first approach to opening the airway of a client who has a suspected

neck injury because in most cases it can be accomplished without extending the neck.

Which intervention has the highest priority when Jonathan is assessed?

A) palpate the lower abdomen for any signs of urinary retention

B) assess sensation by gently pinching the skin distal to proximal

C) assesses Jonathan's breathing pattern and his ability to cough

D)Monitor the clients vital signs especially a Tympanic temperature - ✅C) assess

Jonathan's breathing pattern and his ability to cough. Since cervical spinal cord injury is

suspected, the RN must be aware that edema may ascend the spinal cord, which can

compromise breathing and coughing. Breathing is always a priority, especially when

there is a possibility that oxygenation might be impaired.

Which assessment data wants immediate intervention by the ED RN (select all that

apply)

A)Jonathan complains of a loss of sensation below his shoulders. His skin is flushed

and warm to touch, particularly in the extremities

B) Jonathan has a slight sensation in his right metatarsal's

C) Jonathan his respirations are 20 and unlabored

D) jonathan's blood pressure is 88/48, and his pulse is 50

E) Jonathan appears to have bladder distention - ✅A) Jonathan complains of a loss of

sensation below his shoulders. His skin is flushed and warm to the touch particularly in

the extremities

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HESI Spinal Cord Injury

What should Jonathan's friends do while waiting for emergency personnel to arrive (select all that apply) A) help Jonathan move his legs and assist him to sit up B) place a blanket over Jonathan and make sure no one moves him C) attempt to stabilize his neck with any type of soft material D) carefully put Jonathan in the back of a truck with one man holding his neck E) ensure that the scene around Jonathan is safe and that he's not in any immediate danger - ✅B) place a blanket over Jonathan and make sure no one moves him. any movement or improper handling could cause further damage and loss of neurological function E) ensure that the scene around Jonathan is safe and that he is not in any immediate danger. Ensuring that the scene is safe and protecting Jonathan from any immediate danger is important If respiratory compromise occurs what action should the RN take to keep the airway open without compromising Jonathan's spine further? A) Logroll to side while maintaining neutral alignment B)perform the jaw-thrust technique C)flex the neck with a wedge pillow D)use the chin-lift/head tilt technique - ✅B) perform the jaw-thrust technique. The jaw- thrust is the safest first approach to opening the airway of a client who has a suspected neck injury because in most cases it can be accomplished without extending the neck. Which intervention has the highest priority when Jonathan is assessed? A) palpate the lower abdomen for any signs of urinary retention B) assess sensation by gently pinching the skin distal to proximal C) assesses Jonathan's breathing pattern and his ability to cough D)Monitor the clients vital signs especially a Tympanic temperature - ✅C) assess Jonathan's breathing pattern and his ability to cough. Since cervical spinal cord injury is suspected, the RN must be aware that edema may ascend the spinal cord, which can compromise breathing and coughing. Breathing is always a priority, especially when there is a possibility that oxygenation might be impaired. Which assessment data wants immediate intervention by the ED RN (select all that apply) A)Jonathan complains of a loss of sensation below his shoulders. His skin is flushed and warm to touch, particularly in the extremities B) Jonathan has a slight sensation in his right metatarsal's C) Jonathan his respirations are 20 and unlabored D) jonathan's blood pressure is 88/48, and his pulse is 50 E) Jonathan appears to have bladder distention - ✅A) Jonathan complains of a loss of sensation below his shoulders. His skin is flushed and warm to the touch particularly in the extremities

A loss of sensation below the waist is a sign of spinal shock. Signs of vasodilation of skin below level of injury and pooling of venous return in the periphery are signs of neurogenic shock D) jonathan's blood pressure is 88/48, and his pulse is 50. Hypotension and bradycardia are signs of neurogenic shock. This is a medical emergency that warrants immediate intervention E) Jonathan appears to have bladder distention. Due to the spinal cord injury resulting in spinal shock, bladder paralysis causing urinary retention needs to be addressed and a prescription for placement of an indwelling catheter needs to be initiated Which intervention should the RN implement first? A) assess Jonathan for symptoms of a paralytic ileus B) notify the ED healthcare provider immediately C)assist the HCP in inserting an endotracheal tube D) prepare to administer the vasoconstrictor dopamine - ✅B) notify the ED healthcare provider immediately. This is a medical emergency. Neurogenic shock must be addressed immediately due to the effects of hypotension and bradycardia. Spinal shock is the complete loss of all reflex, motor, sensory, and autonomic activity below the lesion. It is imperative to initiate medical interventions to attempt to lessen the severity of the injury. Which medication(s) should the ED RN expect the HCP to prescribe for Jonathan (select all that apply) A) morphine, and opioid analgesic B) mannitol, and osmotic diuretic C) Methylprednisone sodium succinate, corticosteroid D) dopamine, of a vasopressor E)Acetylsalicytic acid, a nonsteroidal anti-inflammatory drug - ✅C) Methylprednisone sodium succinate, a corticosteroid. This medication, when given within eight hours of injury, decreases inflammation, thereby reducing damage to cell membranes. D)dopamine, a vasopressor. This medication is used in the acute phase as an adjuvant to treatment to maintain mean arterial pressure (MAP)at a greater than 90 mmHg. this will ensure adequate perfusion to the spinal cord. Methylprednisone sodium succinate, is prescribed as 125 mg intravenous piggyback (IVPB) over 30 minutes. The IVPB containing the medication contains 100 mL of fluid. The drop factor on the IV tubing is 10 gtts/mL. At how many drops per minute should the RN regulate the IVPB? - ✅33gtts/ min Which nursing intervention is included in the care plan when managing a client with Gardner-Wells tongs? A) do not remove the traction wait and ensure they hang freely B) ensure that an extra set of drillbits are available in case a new set of predrilled holes must be made in Jonathan's skull C) place the Velcro binders securely around Jonathan's head

B) The client exhibits no reddened areas or breaks in the skin. C) The nursing staff rotates the clients Kinetic bed per unit protocol. D) The physical therapist performed passive range of motion exercises. - ✅B) The client exhibits no reddened areas or breaks in the skin. This outcome is client centered and is directly related to the nursing diagnosis. According to the ethical principle of veracity, how should the RN respond to Jonathan's question? A) are you afraid that you may not be able to walk again? B) I always believe in hope, Jonathan, so you shouldn't give up C) no, Jonathan, it's unlikely you will ever be able to walk again D) I don't think it is a good idea to talk about this. You need sleep. - ✅C) no, Jonathan, it is unlikely that you will ever be able to walk again. Veracity is the ethical principle that is based on telling the truth. One of the night RNs who has been caring for Jonathan since admission has established a therapeutic relationship with him. On numerous occasions they have had meaningful conversations. Tonight Jonathan tells the RN, I don't want to live if people will have to take care of me. Please tell my family and the doctors that I want to die. I don't want any medications or treatments. I have already told them but they won't listen to me. Which intervention should the RN implement? A) reassure Jonathan that everything will be all right and encourage him not to think like that. B) encourage Jonathan to talk to the chaplain about his feelings as soon as possible. C) request the hospital ethics committee to meet and discuss Jonathan's wishes. D) arrange a meeting with Jonathan, his family, and the healthcare team to discuss Jonathan's concerns. - ✅D) arrange a meeting with Jonathan, his family, and the healthcare team to discuss Jonathan's concerns. Client advocacy is a priority for the RN. Actively advocating for clients who are vulnerable or unable to promote their own needs is the correct ethical action to implement. Additionally, such a meeting can facilitate open communication among all the parties involved and any misconceptions can be discussed. Jonathan's mother comes to the nurses station and tells the RN that Jonathan's grandparents have just arrived from Arizona. Jonathan's paternal grandparents live on a Navajo reservation and believe in many old tribal customs. His grandfather is a medicine man who wants to heal Jonathan so that Jonathan can walk again. Jonathan's mother asked if his grandfather can try to heal him. What is the initial best action by the RN? A) explain that the grandfather may visit, but only for 10 minutes during visiting hours. B) discuss the grandfathers desire with Jonathan, and if he agrees, then allow it. C) request an immediate multidisciplinary team meeting to discuss the situation. D) obtain more information about what the grandfather wants to do. - ✅D)obtain more information about what the grandfather wants to do. Nursing staff should make an effort to accommodate cultural requests such as this one, while advocating the treatment regimen and protecting the other clients in the ICU. The RN should obtain more

information first, then ask Jonathan if he agrees, and then meet with the team to determine the parameters of the grandfather's visit. Jonathan's grandfather comes to the nurses station and requests to talk to someone. He wants to heal his grandson. The charge nurse escorts the grandfather back to the office. The grandfather says "Jonathan is sick because he does not practice the old ways. He is being punished for this." How should the RN respond to the statement? A) Jonathan is a fine young man. He did not do anything wrong. This was just an accident. B) just because he does not believe in your way does not mean he is being punished. C) sit quietly and allow the grandfather to continue. D) request that the grandfather wait a minute and ask an HCP to join the meeting. - ✅C) sit quietly and allow the grandfather to continue. A person's culture may influence his or her beliefs about the cause of accident or illness. Clients and families from other cultures may be reluctant to talk to a healthcare professional. Simply listening to them may help them overcome their hesitation. Prior to commenting the RN should learn more about what the grandfather would like to do for his grandson. Jonathan tells the RN "someone said I should have a living will. Can you tell me what that is" How will the RN respond? A) you want to know about a living will? Are you thinking of hurting yourself? B) I will call the chaplain so he can discuss the living will with you C) it's a legal document that helps us make decisions about your health care based on your wishes D) you must appoint someone to make decisions about your treatment if you are unable to do so - ✅C) it's a legal document that helps us make decisions about your health care based on your wishes. A living will is an advance directive the documents a person's wishes concerning treatment when those wishes cannot longer be communicated. The young man who hit Jonathan in the football game comes to the nurses station and ask to see Jonathan. He asks the RN, "how is Jonathan doing? Will he ever walk again? " What is the best response by the RN? A) he's doing better but he will never be able to walk again. B) I am sorry, but I cannot share that information with you. C) Jonathan is in his room, but I don't think you should visit him. D) I think his mother is in the waiting room let me ask her if I can speak with you about Jonathan. - ✅B) I am sorry, but I cannot share that information with you. The health insurance portability and accountability act (HIPAA) mandates that the RN protect the clients personal health information and is given permission by the client to disclose it. What psychosocial intervention by the RN has priority at this time? A) talk to Jonathan's mother about his previous coping skills B) let Jonathan know if he wants to talk or has questions, the RN is available to listen. C) notify the HCP to obtain a psychiatric consultation D) ask Jonathan's mother, girlfriend, and grandparents to limit visits because they seem to cause added stress. - ✅B) let Jonathan know that if you wants to talk or has

Because of his paralysis, Jonathan is at risk for diss use syndrome. Which intervention should the RN implement to address disuse syndrome? A) perform passive range of motion every four hours B) encourage Jonathan to avoid stretching his Achilles tendon C) discuss methods to promote regular mental stimulation D) assess the skin for any reddened areas at least every shift - ✅A)perform passive range of motion exercises every four hours. Jonathan is at risk for the development of contractures as a result of disuse syndrome (atrophy due to loss of motor and sensory functions below the level of injury). Performing ROM exercises every four hours will help prevent disused syndrome. Jonathan's rehabilitation RN, and unlicensed assistive personnel(UAP), and an aid are caring for six clients on the unit. Which task should the RN delegate to the UAP? A) teach Jonathan how to use the electric wheelchair. B) assess Jonathan's ability to perform activities of daily living ADLs. C)Measure the intake and output for the client taking diuretics. D) discuss appropriate ways to prevent urinary tract infections - ✅C) Measure the intake and output for the client taking diuretics. The UAP can obtain the intake and output measurements, but any assessments about the effectiveness of diuretics remain the responsibility of the RN. The rehabilitation RN is observing the UAP caring for a paraplegic client on the unit. Which behavior by the UAP warrants immediate intervention by the RN? A) The UAP is feeding the client. B) The UAP is taking a Tympanic temperature C) The UAP is emptying the Foley catheter bag D) The UAP is placing socks on the clients feet - ✅A)The UAP is feeding the client. The client is tetraplegic, and therefore has the use of upper extremity's with adaptive utensils. During the rehabilitation phase of care, Independence must be encouraged, so the client should not be fed by another individual. Jonathan tells the RN "I am afraid my girlfriend will leave me, but I can't blame her for leaving someone who can't even hold her hand". Which intervention should the RN implement first? A) encourage Jonathan to talk to his girlfriend about his concerns B) refer Jonathan and his girlfriend to a counselor for sexual education C) ask Jonathan if he would like to share his fears about life after leaving the hospital. D) request a meeting with Jonathan's healthcare team. - ✅C) ask Jonathan if he would like to share his fears about life after leaving the hospital. The RN should first directly address Jonathan's fears and concerns and then encourage Jonathan to talk with his girlfriend. Referral for sexual counseling and a team meeting can be initiated at a later time. Jonathan voices his concerns about how he will be able to make a living after being released from the rehabilitation unit. Prior to the accident he worked at a local factory

and attended a community college. His goal is to become a fireman, like his father. Which action should the RN implement? A) refer Jonathan to a local counselor for vocational rehabilitation B) discuss the Americans With Disabilities Act with Jonathan and his mother C) suggest that Jonathan apply for disability payments and not worry about working D) reassure Jonathan that everything will be all right after he goes home - ✅A) referred Jonathan to a local counselor for vocational rehabilitation. Vocational rehabilitation counselors assist clients with disabilities and planning careers and finding jobs. Jonathan is only 22 years old, and he needs to be productive. Jonathan is now being discharged to his mothers home. His mother and his girlfriend will work together to provide care for Jonathan. The RN is teaching Jonathan, his mother, and his girlfriend about muscle spasticity. It is one of the most common complications of tetraplegia. Which intervention will the RN include when discussing ways to prevent muscle spasticity? A) encourage Jonathan to use footboards at all times B) perform stretching exercises 5 to 7 times each day C) instruct Jonathan to lay in the prone position for two hours daily D) take the prescribed antibiotic when the spasms of her - ✅B) perform stretching exercises 5 to 7 times each day. Stretching exercises are an effective, non-invasive treatment for spasticity. Stretches should be held for 45 to 90 seconds. They must be done 5 to 7 times per day because the effect on spasticity generally lasts only a few hours. The RN is discussing bladder management with Jonathan and his mother. Jonathan has a spastic bladder and has been wearing a condom catheter. Which statement by Jonathan's mother indicates that she has an understanding of the bladder care plan designed for Jonathan? A) I will limit Jonathan's fluid intake so the drainage bag won't fill up so quickly B) I should remove the condom catheter nightly to clean his penis C) once the condom catheters applied, I do not need to check it D) if the catheter is draining slowly, I should immediately catheterize Jonathan to empty his bladder. - ✅B)I should remove the condom catheter nightly to clean his penis. Warm urine on the periurethral skin promotes bacterial growth and colonization. The condom catheter should be removed and the skin clean and inspected daily Which member of the rehabilitation multidisciplinary team is responsible for ensuring that Jonathan will be discharged to a home that is equipped to care for him? A) The recreational therapist B) The physiatrist C) The occupational therapist D) The cognitive therapist - ✅C)The occupational therapist. This team member works to develop the clients fine motor skills used for activities of daily living and will do a home evaluation to determine what must be done so that Jonathan can function in the home as independently as possible.

HESI Spinal Cord Injury., Exams of Nursing

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HESI Spinal Cord Injury