A patient with an incomplete spinal cord injury is being transferred from intensive care to the neurological trauma unit
The nurse realizes that in order to minimize the patient's risk of developing autonomic hyperreflexia, which interventions should be included in the patient's care plan? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Monitoring skin temperature in lower extremities
2. Assessing for abdominal distention
3. Bladder scan postvoiding
4. Assessing pulse oximetry levels with vital signs
5. Strict output monitoring
2,3,5
Rationale 1: Monitoring lower-extremity skin temperature is appropriate for detecting deep vein thrombosis.
Rationale 2: Causes of autonomic hyperreflexia are impacted stool or constipation, so assessing for abdominal distention is appropriate.
Rationale 3: The nurse caring for spinal cord injury (SCI) patients should be attuned to the prevention of a distended bladder to prevent the chain of events that leads to autonomic hyperreflexia. Scanning the bladder postvoiding can detect residual urine retention.
Rationale 4: Pulse oximetry is effective in monitoring for a decline in oxygen saturation and may be the initial indicator of a pulmonary embolus.
Rationale 5: Tracking urinary output carefully can help detect residual urine retention.
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The nurse knows that medication teaching has been ineffective when the client with an anxiety disorder states, "My SSRI isn't working. I've been on it for:
1. One week." 2. Four weeks." 3. 12 weeks." 4. Eight weeks."
The sister of a patient in the ICU has been at the patient's bedside non-stop for 48 hours. The nurse suggests to her that she return home to rest. Which of the following is the proper rationale for the nurse making such a suggestion?
A) The sister is in the way of the health care providers. B) The patient may become annoyed by her continual presence. C) The patient will recover more easily in peace and quiet. D) The sister needs to maintain her own health during this time.
With regard to eventual discharge of the high risk newborn or transfer to a different facility, nurses and families should be aware that
a. Infants will stay in the NICU until they are ready to go home. b. Once discharged to home, the high risk infant should be treated like any healthy term newborn. c. Parents of high risk infants need special support and detailed contact information. d. If a high risk infant and mother need transfer to a specialized regional center, it is better to wait until after birth and the infant is stabilized.
A nurse is teaching a class about emergency preparedness and violence. Which of the following factors is associated with an increased risk of being the victim of violence or intentional harm? Select all that apply
A. Age between 15 and 44 B. Poor mental health C. Substance abuse D. Male gender E. Low socioeconomic status