A patient is admitted with an acute spinal cord injury. The nurse is continuing to assess the patient for neurological deficits and sensory and motor functioning because of which of the following?
1. potassium causes destruction of the myelin
2. ischemia can increase the zone of injury
3. inflammatory process is delayed in spinal cord injuries
4. inflammation increases the blood flow to the damaged area of the cord
2
Rationale: Blood flow to the spinal cord decreases immediately on injury as a result of hypotension and vasospasm induced thrombosis. Thrombi in the microcirculation impede blood flow. The zone of ischemia can spread if perfusion to the cord is not restored. Calcium is released in a spinal cord injury and is responsible for demyelization. The inflammatory process is not delayed in spinal cord injuries. Inflammation causes edema which further reduces the blood flow to the damaged cord.
You might also like to view...
A nurse has found a patient with delirium in other patients' rooms several times. What is the best action by the nurse?
a. Firmly tell the patient that he must stay out of other patients' rooms and tell him to return to his room. b. Take him back to his room and put him in bed with the side rails up. c. Take him to the nurses' station and let him visit for a while. d. Administer a dose of lorazepam (Ativan) as ordered.
Which of the following would be a priority goal for a patient with stroke-related sensory perception alterations?
1. protect from injury 2. promote increased tactile stimulation 3. increase perception of sensations 4. increase attention to hazards in the environment
Which of the following are included in the guidelines for valuable, effective acknowledgement of each member's contribution to the team?
a. Acknowledgments should be made pri-vately to avoid embarrassing the person. b. Acknowledgments are best put into the minutes to be read at a later date. c. Acknowledgments are best made in public and recognized as sincere. d. Acknowledgments are not necessary; everyone recognizes what has been done.
The nurse is working on the orthopedic unit, and is caring for a client who complains of back pain. Which responses by the nurse would be appropriate when caring for this client?
1. "I'm sorry you're hurting. I want to make you feel better." 2. "People with back pain experience very different symptoms. Tell me more about your back." 3. "You had medication for your pain at 4 p.m., so I can't give you any more until 8 p.m., because the health care provider ordered it every 4 hours." 4. "Does anything other than your back hurt?" 5. "Why don't you try another position to make it feel better until it's time for more pain medication?"