Following a cauda equina spinal cord injury, which action will the nurse include in the plan of care?
a. Catheterize patient every 3 to 4 hours.
b. Assist patient to ambulate several times daily.
c. Administer medications to reduce bladder spasm.
d. Stabilize the neck when repositioning the patient.
ANS: A
Patients with cauda equina syndrome have areflexic bladder, and intermittent catheterization will be used for emptying the bladder. Because the bladder is flaccid, antispasmodic medications will not be used. The legs are flaccid with cauda equina syndrome and the patient will be unable to ambulate. The head and neck will not need to be stabilized following a cauda equina injury, which affects the lumbar and sacral nerve roots.
You might also like to view...
The nurse is caring for a 25-year-old soldier on the day following an enucleation due to traumatic injury. The soldier states, "My girlfriend probably won't have anything to do with me since I'll never look the same!"
What is an appropriate response by the nurse? 1. "You'll probably get your temporary prosthesis in a week and your permanent one in 1 or 2 months. Most people won't know which eye is which." 2. "I wouldn't worry; your girlfriend is not going to give up on you." 3. "Your hearing aid will be nearly invisible; no one will know you have one." 4. "Why don't you tell a couple of your friends to bring you a pizza? That will cheer you up."
Which position is tolerated by most older persons?
a. Fowler's position b. Trendelenburg position c. Sims' position d. The prone position
Which of the following values can be derived from a drug-response curve and used to compare the potency of drugs that produce the same response?
A. Half-life B. Drug clearance C. Infusion rate D. Effective dose 50
The nurse is assessing a patient with polycythemia vera. Which finding is consistent with this disorder?
a. Pallor b. Blood pressure (BP) of 100/60 c. Hemoglobin of 17 mg/dL d. Agitation