A patient is admitted after a fall that has resulted in spinal shock. When asked by the family how long the paralysis is likely to last, the nurse's response is based on which understanding?
1. Spinal shock usually results in temporary paralysis.
2. There will likely be some minor improvement in the degree of paralysis.
3. Spinal shock is irreversible and the paralysis is likely to be permanent.
4. The severity of the injuries cannot be determined until the spinal shock resolves.
4
Rationale 1: At this point it is not possible to determine whether the paralysis is temporary or permanent or will lessen.
Rationale 2: There is no assurance that the paralysis will lessen.
Rationale 3: The duration of spinal shock is quite variable, lasting as little as a few hours or as long as several weeks after injury. During this period, it is impossible to determine the extent of the SCI.
Rationale 4: Spinal shock is a state of areflexia in which there is a loss of all motor, sensory, and reflex activity at the level of the injury and below. It is not possible to determine the severity of the injury until spinal shock has abated.
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A) Assist the patient in determining signs of neuromuscular weakness B) Instruct the man on treatment options for Huntington disease C) Teach the man how to avoid passing Huntington disease to his own children D) Provide genetic counseling, evaluation, and testing for the disease
The nurse preceptor is giving a seminar about recognition and assessment of coping mechanisms found in older adult patients in crisis to a group of novice nurse. Which statement by the novice nurse indicates that the teaching has been effective?
1. "Older adult patients generally do not have well-established coping mechanisms." 2. "Older adult patients generally use physiological coping due to their advanced age." 3. "Older adult patients in crisis are more likely to suffer from a lack of social support." 4. "Older adult patients in crisis are more likely to suffer from a lack of belief-based coping."
The nurse is teaching parents ways to give oral medication to their child. Which action would they implement to improve compliance?
a. Crush time-release capsules to put in his favorite food. b. Give medication quickly before he knows what is happening. c. Allow the child to eat a frozen pop before receiving the medication. d. Mask the flavor of medication in a toddler cup with orange juice.
Where in the health history does a record of immunizations belong?
a. History b. Present illness c. Review of systems d. Physical assessment