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HESI Case Study: Spinal Cord Injury
Terms in this set (35)
Meet the Client: Ryan Stapleton
Ryan Stapleton is a 20-year-old college student attending school term-0in Colorado away from his home in Arizona. He is playing football with some of his friends in the park. He jumps up in the air to catch the football and is tackled by another player. Ryan flips in midair and feels something pop in his neck as he lands hard on the ground. He does not have any pain, but when he tries to get up, he cannot move his legs or arms. Ryan is alert and is talking to his friends.
What should Ryan's friends do while waiting for emergency personnel to arrive? (Select all)
-Place blanket over Ryan and make sure no one moves him
-Ensure that the scene around Jonathan is safe and that he is not in any immediate danger
If respiratory compromise occurs, what action should the nurse take to keep the airway open without compromising Ryan's spine further?
Perform the jaw-thrust technique
Which intervention has highest priority when assessing Ryan?
Assess Ryan's breathing pattern and his ability to cough
Ryan is scheduled to have an open CT scan with contrast procedure. What questions should be asked prior to administering intravenous contrast to Ryan's saline lock?
- What happens when he eats shellfish (crustaceans)
- Does he have an allergy to iodine
After the CT scan is complete, Ryan is transported to the MRI scan. 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?
Which assessment data warrants immediate intervention by the ED RN?
-Ryan complains of a loss of sensation below his shoulders. His skin is flushed and warm to touch, particularly in the extremities
-Ryan's blood pressure is 80/45, and his pulse is 48
-Ryan appears to have bladder distention
Ryan is experiencing the signs and symptoms of spinal shock and neurogenic shock.
What intervention should the nurse implement first?
Notify the ED healthcare provider (HCP) immediately
Which nursing intervention is included in the care plan when managing a client with Gardner-Wells tongs?
Do not remove the traction weights and ensure they hang freely
Which intervention should be implemented for a paralytic ileus?
Obtain an order to insert a nasogastric tube and set the siphon drainage to a low, intermittent suction
10. Which nursing diagnosis has priority at this time?
Risk for impaired skin integrity
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
Ryan tells the nurse, "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 nurse implement?
Arrange a meeting with Ryan, his family, and the healthcare team to discuss Ryan's concerns
The nurse is walking by the Neuro-ICU waiting room and notices Ryan's mother sitting and crying. There is no one else in the waiting room.
What action should the nurse implement at this time?
Sit down beside Ryan's mother
Ryan has autonomic dyreflexia
Evaluate the teaching, the nurse asked Ryan to explain his understanding of all instructions given. Which statements indicate Ryan's understanding?
- It's important to drink hot fluids prior to defecation
-Plan bowel evacuation at the same time every day
- I should empty my bladder at least every 2 to 3 hours
- if I have a pounding headache, I should move to a sitting position
What is the best initial action by the nurse?
Obtain more information about what the grandfather want to do
How should the nurse respond to this statement?
Sit quietly and allow the grandfather to continue
Jonathon wants to know what a living will is. How should the nurse respond?
"It is a legal document that helps us make decisions about your healthcare, based on you wishes."
What is the best response by the nurse?
"I am sorry, but I cannot share that information with you."
Methylprednisolone Sodium Succinate (Solu-Medrol), is prescribed as 125 mg intravenous piggy back (IVPB) over 30 minutes. The IVPB containing the medication contains 100 mL of fluid. The drop factor on the IV tubing is10 gtts/min. How many drops/min (gtts/min) should the nurse regulate the IVPB? (If applicable, round to the whole number)
Which intervention(s) should the RN implement to address this concern? (Select all)
-Allow Jonathan to watch television as much as he likes
-Encourage Jonathan's girlfriend to talk to him during visits
-Provide Jonathan prism glasses, and tell him how to use them
Which psychosocial intervention by the nurse has priority at this time?
Let Jonathan know that if he wants to talk or has questions, the RN is available to listen
What medication(s) should the ED RN expect the HCP to prescribe for Jonathan? (Select all)
-Methylprednisolone sodium succinate, a corticosteriod
-Dopamine, a vasopressor
Which statement by Jonathon indicates an understanding of autonomic dysreflexia?
"I should empty my bladder at least every 2 to 3 hours."
Which intervention should the nurse implement first?
Move Jonathan to a sitting position
Which intervention should the nurse implement to address disuse syndrome?
Perform passive range of motion (ROM) exercises every 4 hours
Which task can the nurse delegate to the UAP?
Measure the intake and output for the client taking diuretics
Which behavior by the UAP warrants immediate intervention by the RN?
The UAP is feeding the client
Which intervention should the RN implement first?
Ask Jonathan if he would like to share his fears about life after leaving the hospital
Which action should RN implement
Refer Jonathan to a local counselor for vocational rehabilitation
Which intervention will the RN include when discussing ways to prevent muscle spasticity
Perform stretching exercises five to seven times each day
Which statement made by Jonathan's mother indicate that she understands bladder care for jonathan
"I should remove the condom catheter nightly to clean his penis."
Which member of the rehab multidisciplinary team is responsible for ensuring that Jonathan will be discharged to a home that is equipped with care for him?
The occupational therapist
Which area has priority according to Maslow's heirarchy of needs
Instructions concerning ways to prevent urinary tract infections
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