HESI Case Studies–Medical/Surgical-Spinal Cord Injury (Jonathan Begay)

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
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
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6. What medication(s) should the ED RN expect the HCP to prescribe for Jonathan? (Select all)
-Methylprednisolone sodium succinate, a corticosteriod
-Dopamine, a vasopressor
7. 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)
33
8. 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
9. Which intervention should be implemented for a paralytic ileus?
Insert a nasogastric tube and set the siphon drainage to a low, intermittent suction
10. 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
11. Which nursing diagnosis has 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
13. According to the principle of veracity, how should the RN respond to Jonathan’s question?
“No Jonathan; it is unlikely that you will ever be able to walk again.”
14. Which intervention should the nurse implement?
Arrange a meeting with Jonathan, his family, and the healthcare team to discuss Jonathan’s concerns
15. What is the best initial action by the nurse?
Obtain more information about what the grandfather want to do
16. How should the nurse respond to this statement?
Sit quietly and allow the grandfather to continue
17. 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.”
18. What is the best response by the nurse?
“I am sorry, but I cannot share that information with you.”
19. 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
20. What action should the nurse implement at this time?
Sit down beside Jonathan’s mother
21. Which information should the nurse include when discussing a bowel elimination program with Jonathon?
Plan bowel evacuation at the same time every day
22. Which statement by Jonathon indicates an understanding of autonomic dysreflexia?
“I should empty my bladder at least every 2 to 3 hours.”
23. Which intervention should the nurse implement first?
Move Jonathan to a sitting position
24. Which intervention should the nurse implement to address disuse syndrome?
Perform passive range of motion (ROM) exercises every 4 hours
25. Which task can the nurse delegate to the UAP?
Measure the intake and output for the client taking diuretics
26. Which behavior by the UAP warrants immediate intervention by the RN?
The UAP is feeding the client
27. Which intervention should the RN implement first?
Ask Jonathan if he would like to share his fears about life after leaving the hospital
28. Which action should RN implement
Refer Jonathan to a local counselor for vocational rehabilitation
29. Which intervention will the RN include when discussing ways to prevent muscle spasticity
Perform stretching exercises five to seven times each day
30. 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.”
31. 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
32. Which area has priority according to Maslow’s heirarchy of needs
Instructions concerning ways to prevent urinary tract infections
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