Spinal Cord Injury Case Study

What should Jonathon’s friends do while waiting for emergency personnel to arrive?
a) Help Jonathon move his legs and sit up
b) Place a blanket over Jonathon and make sure no one moves him
c) Attempt to stabilize his neck with any type of soft material
d) Carefully put Jonathon in the back of a truck with someone holding his neck
b) Place a blanket over Jonathon and make sure no one moves him
Rationale: Any movement or improper handling could cause further damage and loss of neurological function.
An ambulance arrives and a nurse and paramedics prepare Jonathon for transport. If respiratory compromise occurs, what action should the nurse take to keep the airway open without compromising Jonathon’s spine further?
a) Logroll to side while maintaining neutral alignment
b) Perform the jaw-thrust technique
c) Flex the neck w/ a wedge pillow
d) Use the chin-lift/head-tilt technique
b) Perform the jaw-thrust technique
Rationale: This is the safest first approach to opening the airway of a casualty who has a suspected neck injury b/c in most cases it can be accomplished without extending the neck.
When Jonathon is admitted to the ED a nurse performs a neuro assessment. Which intervention has highest priority when assessing Jonathon?
a) Palpate the lower abdomen for any signs of urninary retention
b) Assess sensation by gently pinching the skin distal to proximal
c) Assess Jonathon’s breathing pattern and his ability to cough
d) Monitor the client’s vital signs, especially the tympanic temperature
c) Assess Jonathon’s breathing pattern and his ability to cough
Rationale: Since a cervical spinal cord injury is suspected, the nurse must be aware that edema may ascend the spinal cord, which can compromise breathing and coughing. Breathing is ALWAYS the priority, especially when there is possibility that oxygenation might be impaired.
Which assessment data warrants immediate intervention by the ED nurse?
a) Jonathon has a slight sensation in his right metatarsals
b) Jonathon’s respirations are 20 and unlabored
c) Jonathon’s BP is 96/60 and his pulse is 48
d) Jonathon is complaining of a headache
c) Jonathon’s BP is 88/50 and his pulse is 50
–appears to have bladder distention
–loss of sensation to shoulder, skin flushed, warm to touch especially in EXT.

Rationale: Hypotension and bradycardia are signs of neurogenic shock. This is a medical EMERGENCY that warrants IMMEDIATE intervention.

The nurse recognizes that Jonathon is experiencing spinal shock. What intervention should the nurse implement first?
a) Assess Jonathon for symptoms of a paralytic ileus
b) Notify the ED physician immediately
c) Assist the physician to insert an endotracheal tube
d) Prepare to administer the vasoconstrictor, dopamine
b) Notify the ED physician immediately
Rationale: This is a medical emergency. Spinal shock is the complete loss of all reflex, motor, sensory, and autonomic activity below the lesion. It is imperative to reverse spinal shock as quickly as possible.

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What medication should the ED nurse expect the physician to prescribe for Jonathon?
a) Morphine, an opioid analgesic
b) Mannitol (Osmitrol), an osmotic diuretic
c) Methylprednisolone Sodium Succinate (Solu-Medrol), a corticosteroid
d) Acetylsalicylic acid (Aspirin), an NSAID
c) Methylprednisolone Sodium Succinate (Solu-Medrol), a corticosteroid
–dopamine, vasopressor

Rationale: This medication, when given within 8 hours of injury, decreases inflammation, thereby reducing damage to cell membranes.

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 gtts/min
Jonathon is admitted to the neuro ICU. His cervical spine is stabilized with Gardner-Wells tongs. He is alert and oriented and denies any pain or discomfort at this time. He is unable to move any extremities and has sensory deficits from the chest down. Which nursing intervention is included in the care plan when managing a client with Gardner-Wells tongs?
a) Do not remove the traction weights and ensure they hang evenly
b) Ensure that an extra set of drill bits are available in case a new set of predrilled holes must be made in Jonathon’s skull
c) Place the Velcro binders securely around Jonathon’s head
d) Apply a halo vest when Jonathon is in an upright position
a) Do not remove the traction weights and ensure they hang evenly
Rationale: Traction is applied to the tongs by employing weights to maintain alignment. Removing the weights would result in misalignment, possibly creating further damage. Weights should hang freely so they do not interfere with the traction. Jonathon should also be assessed for evidence of infection at the spring-loaded pin sites.
Which intervention should be implemented for a paralytic ileus?
a) Encourage Jonathon to eat a high fiber, high calorie diet
b) Turn Jonathon every 2 hours in the kinetic bed
c) Insert a nasogastric tube and set the siphon drainage to a low, intermittent suction
d) Continue to assess Jonathon but take no action at this time
c) Insert a nasogastric tube and set the siphon drainage to a low, intermittent suction
Because Jonathon needs to remain flat in bed while in traction, the nurse is concerned that he may experience sensory and perceptual problems. Which intervention(s) should the nurse implement to address this concern? (Select all that apply)
a) Allow Jonathon to watch TV as much as he likes
b) Encourage Jonathon’s girlfriend to talk with him during visits
c) Provide Jonathon prism glasses, and tell him how to use them
d) Discuss ways for Jonathon to deal with his depression
e) Restrict visitors to the immediate family only
a) Allow Jonathon to watch TV as much as he likes
b) Encourage Jonathon’s girlfriend to talk with him during visits
c) Provide Jonathon prism glasses, and tell him how to use them
Rationale: TV promotes sensory stimulation. Interaction stimulates. Prism glasses enable patients to see from the supine position.
Which nursing diagnosis has priority at this time?
a) Self-care deficit
b) Disturbed sensory perception
c) Risk for impaired skin integrity
d) Risk for ineffective coping
c) Risk for impaired skin integrity
Rationale: Immobility always increases the client’s risk for impaired skin integrity. Skin sores are the most common and devastating complication of SCI. Maslow’s Hierarchy of Needs addresses physiological needs first.
The nurses includes the nursing diagnosis “risk for impaired skin integrity related to immobility and sensory loss.” Which outcome should the nurse use for evaluation of the efficacy of interventions designed for this nursing diagnosis?
a) The client’s family inspects the skin for reddened areas daily
b) The client exhibits no reddened areas or breaks in the skin
c) The nursing staff rotates the client’s kinetic bed per unit protocol
d) The physical therapist performs passive range of motion exercises
b) The client exhibits no reddened areas or breaks in the skin
Rationale: This outcome is client-centered and directly related to the nursing diagnosis
Jonathon tells the nurse, “Today the doctor told me I will never walk again. Do you think that I will ever be able to walk again?” According to the principle of veracity, how should the nurse respond to Jonathon’s question?
a) “Are you afraid that you might not be able to walk again?”
b) “I always believe in hope, Jonathon, so you shouldn’t give up”
c) “No, Jonathon; it is unlikely that you will ever be able to walk again”
d) “I don’t think this is a good time to talk about this. You need to sleep”
c) “No, Jonathon; it is unlikely that you will ever be able to walk again”
Rationale: Veracity is the ethical principle that is based on telling the truth
Jonathon tells the nurse, “I don’t want to live if people 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?
a) Reassure Jonathon that everything will be all right and encourage him not to think like that
b) Encourage Jonathon to talk to the chaplain about his feelings as soon as possible
c) Request the hospital ethics committee to meet and discuss Jonathon’s wishes
d) Arrange a meeting with Jonathon, his family, and the healthcare team to discuss Jonathon’s concerns
d) Arrange a meeting with Jonathon, his family, and the healthcare team to discuss Jonathon’s concerns
Rationale: Client advocacy is a priority for the nurse. Actively advocating for client’s 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 of the parties involved and any misconceptions can be discussed.
Jonathon’s grandparents have just arrived Arizona where Jonathon’s grandfather is a Navajo medicine man. He wants to heal Jonathon so he can walk again and his mom asks if that’s okay. What is the best initial action by the nurse?
a) Explain that the grandfather may visit, but only for 10 minutes during visiting hours
b) Discuss the grandfather’s desire with Jonathon, and if he agrees, then allow it
c) Request an immediate multidisciplinary team meeting to discuss this situation
d) Obtain more information about what the grandfather wants to do
d) Obtain more information about what the grandfather wants to do
Rationale: 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 nurse should obtain more information first, then ask Jonathon if he agrees, then meet with the team to determine the parameters of the grandfather’s visit.
Jonathon’s grandfather says that Jonathon is sick because he does not practice the old ways and is being punished for it. How should the nurse respond to this statement?
a) “Jonathon 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 ways 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 a physician to join the meeting
c) Sit quietly and allow the grandfather to continue
Rationale: A person’s culture may influence their beliefs about the cause of accidents or illnesses. Clients and families from other cultures may be reluctant to talk to health professionals. Simply listening to them may help them overcome their hesitation. Prior to commenting, the nurse should learn more about what the grandfather would like to do for his grandson.
Jonathon wants to know what a living will is. How should the nurse 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 is a legal document that helps us make decisions about your healthcare, based on your wishes”
d) “You must appoint someone to make decisions about your treatment if you are unable to do so”
c) “It is a legal document that helps us make decisions about your healthcare, based on your wishes”
Rationale: A living will is an advance directive that documents a person’s wishes concerning treatment when those wishes can no longer be communicated
The young man who hit Jonathon comes and asks the nurse how Jonathon is doing. What is the best response by the nurse?
a) “He is doing better, but he will never be able to walk again”
b) “I am sorry but I cannot share that information with you”
c) “Jonathon 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 Jonathon”
b) “I am sorry but I cannot share that information with you”
Rationale: HIPPA mandates that the nurse protects the client’s personal health information unless given permission by the client to disclose it
Jonathon is very quiet and does not speak except to answer questions. Which psychosocial intervention by the nurse has priority at this time?
a) Talk to Jonathon’s mother about his previous coping skills
b) Let Jonathon know that if he wants to talk or has questions, the nurse is available to listen
c) Notify the healthcare provider to obtain a psychiatric consult
d) Ask Jonathon’s mother, girlfriend, and grandparents to limit visits because they seem to cause added stress
b) Let Jonathon know that if he wants to talk or has questions, the nurse is available to listen
Rationale: This option gives Jonathon more options to talk about his feelings without forcing him to do so.
The nurse notices Jonathon’s mother crying. What action should the nurse implement at this time?
a) Allow Jonathon’s mother to cry and do not disturb her at this time
b) Ask the hospital chaplain to come and see Jonathon’s mother
c) Sit down beside Jonathon’s mother
d) Discuss the situation with Jonathon as soon as possible
c) Sit down beside Jonathon’s mother
Rationale: Offering a caring, supporting presence to Jonathon’s mother is the priority intervention at this time. It provides an opportunity for Jonathon to share her feelings, if she desires to do so.
Jonathon has a reflexic bowel and a bowel program is instituted so Jonathon can have bowel movements. Which information should the nurse include when discussing a bowel elimination program with Jonathon?
a) Explain the importance of drinking cold fluids prior to defecation
b) Plan bowel evacuation for the same time every day
c) The importance of turning to his right side
d) Daily enemas will be needed to achieve a bowel movement
b) Plan bowel evacuation for the same time every day
Rationale: Bowel care is best when scheduled at the same time every day in order to develop a habitual response
Which statement by Jonathon indicates an understanding of autonomic dysreflexia?
a) “If I start feeling lightheaded when I get up, I should raise my head more slowly”
b) “I should empty my bladder at least every 2-3 hours”
c) “It is a complication that occurs if my extremities aren’t moved every 2 hours”
d) “It’s an automatic response that occurs whenever I have a bowel movement”
b) “I should empty my bladder at least every 2-3 hours”
Rationale: Autonomic dysreflexia occurs as a result of an overfull bladder, although it can be brought on by other noxious stimuli. It can develop suddenly, and if it is not treated promptly, it can lead to seizures, stroke and death. Therefore, prevention is very important.
Jonathon complains of a pounding headache. Which intervention should the nurse implement first?
a) Assess Jonathon’s bladder for distension
b) Move Jonathon to a sitting position
c) Administer a ganglionic blocking agent IVP
d) Attempt to determine what triggered the headache
b) Move Jonathon to a sitting position
Rationale: The client may be experiencing autonomic dysreflexia, an exaggerated autonomic response to a noxious stimulus resulting in hypertension and a pounding headache. Putting Jonathon in a sitting position will help to lower the BP. The nurse can then assess for the stimulus and administer medications if needed.
Which intervention should the nurse implement to address disuse syndrome?
a) Perform passive ROM exercises every 4 hours
b) Encourage Jonathon 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 ROM exercises every 4 hours
Rationale: Jonathon is at risk for developing contractures as a result of disuse syndrome (atrophy due to loss of sensory and motor functions below the level of injury). Performing ROM exercises every 4 hours will help prevent disuse syndrome.
Which task can the nurse delegate to the UAP?
a) Teach Jonathon how to use the electric wheelchair
b) Assess Jonathon’s ability to perform activities of daily living
c) Measure the I&O for the client taking diuretics
d) Discuss appropriate ways to prevent UTIs
c) Measure the I&O for the client taking diuretics
Rationale: The UAP can obtain I&Os but any assessment about the effectiveness of diuretics remains the responsibility of the nurse
The UAP is caring for a paraplegic client. Which behavior by the UAP warrants immediate intervention by the nurse?
a) The UAP is feeding the client
b) The UAP is taking the tympanic temperature
c) The UAP is emptying the Foley catheter
d) The UAP is placing socks on the client’s feet
a) The UAP is feeding the client
Rationale: The client is paraplegic so has use of the upper extremities. During the rehab phase of care, independence must be encouraged, so the client should not be fed
Which intervention should RN implement first?
a) request meeting with jonathans health care team
b) Ask Jonathan is he would like to share his fears about after leaving hospital
c) encourage Jonathan to talk to his G/F about his concerns
d) Refer Jonathan & his GF to a counselor for sex ed.
— Ask Jonathan is he would like to share his fears about after leaving 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 5-7 times each day
which stat ement 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?
–occupational therapist
which area has priority according to Maslow’s heirarchy of needs
–instructions on ways to prevent UTI
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