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HESI Case Studies Spinal Cord Injury (RYAN)

Terms in this set (14)

1. What should Jonathan's friends do while waiting for emergency personnel to arrive? (Select all)
-Place blanket over Jonathan and make sure no one moves him

-Ensure that the scene around Jonathan is safe and that he is not in any immediate danger
2. If respiratory compromise occurs, what action should the nurse take to keep the airway open without compromising Jonathan's spine further?
Perform the jaw-thrust technique
3. Which intervention has highest priority when assessing Jonathan?
Assess Jonathan's breathing pattern and his ability to cough
What questions should be asked prior to administering the intravenous contrast through Ryan's saline lock?
what happens when he eats shellfish?

Does he have an allergy to iodine
what questions are appropriate to ask ryan prior to beginning the procedure
Is he claustrophobic or afraid of closed-in, small places?

Does he have any metal piercings on his body or metal implants?
4. Which assessment data warrants immediate intervention by the ED RN? (Select all)
-Jonathan complains of a loss of sensation below his shoulders. His skin is flushed and warm to touch, particularly in the extremities

Jonathan's blood pressure is 88/48, and his pulse is 50


-Jonathan appears to have bladder distention
5. What intervention should the nurse implement first?
Notify the ED healthcare provider (HCP) immediately
8. Which nursing intervention is included in the care plan when managing a client with Gardner-Wells tongs?F
Do not remove the traction weights and ensure they hang freely
Which nursing diagnosis is of highest priority at this time
risk for impaired skin integrity
12. Which outcome should the RN use for evaluation of the efficacy of interventions designed for this nursing diagnosis?
The client exhibits no reddened areas or breaks in the skin
14. Which intervention should the nurse implement?
Arrange a meeting with Jonathan, his family, and the healthcare team to discuss Jonathan's concerns
You see Ryan's mother crying. What action should the nurse implement at this time?
Sit down beside Ryan's mother
To evaluate the teaching, the nurse asks ryan to explain his understanding of all instructions given. Which statements indicate Ryan's understanding?
A. it is important to drinking hot fluids prior to defecation

B. I will plan bowel evacuation at the same time every day

C. i should empty my bladder at least every 2- 3 hours

E. If i have a pounding headache, i should move to a sitting position
9. Which intervention should be implemented for a paralytic ileus?
Insert a nasogastric tube and set the siphon drainage to a low, intermittent suction
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