The nurse is caring for a patient involved in a motorcycle accident. After admission to the intensive care unit, the nurse assesses the patient for symptoms of spinal shock. Which of the following findings indicates the presence of spinal shock?
a. Loss of motor control below the level of the injury with sensations of touch and position intact
b. Flaccid paralysis and lack of sensation below the level of the injury
c. Loss of voluntary motor control, but presence of reflex activity below the level of the injury
d. Falling blood pressure and rising pulse accompanied by reduced level of consciousness
ANS: B
Immediately following injury, the cord below the injury stops functioning completely, causing loss of motor and sensory functions as well as reflexes. Falling blood pressure and rising pulse indicate shock from blood loss or cardiovascular cause.
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The nurse is providing discharge instructions to a patient recovering from a total hip replacement
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The "PIE" format is used on the nursing unit. Which entry should the nurse place in the "E" part of the format?
a. Pain level 4/10 gnawing and constant. b. Lung sounds clear bilaterally. c. Patient states, "I don't want the blood transfusion because of the problems I had before.". d. Pain level 2/10 30 minutes after receiving pain medication.
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a. Telling the person when you are coming to a curb or steps b. Telling the person when to step up or down c. Having the person walk slightly behind you d. Using phrases like "over here" or "over there"