100%(8)8 out of 8 people found this document helpful
This preview shows page 8 - 10 out of 27 pages.
Question 12Type: MCSAHow should the nurse explain to a patient with a spinal cord injury why the extent of injury cannot be determined for several days to a week?1. “Tissue repair does not begin for 72 hours.”2. “We have to wait until spinal shock resolves.”3. “Neurons need time to regenerate, so it is hard to predict how you will progress.”4. “The most serious changes after an injury take days to develop.”Correct Answer: Rationale 1: The inability to determine the extent of injury is not related to delayed tissue repair.Rationale 2: Spinal shock is a state of areflexia that occurs as a result of primary injury. It is not possible to determine the extent of injury until this condition abates.Rationale 3: Neurons do not regenerate.Rationale 4: Within 24 hours of the injury, necrosis of both gray and white matter begins if ischemia has been prolonged and the function of nerves passing through the injured area is lost.2Global Rationale:
Cognitive Level: AnalyzingClient Need: Physiological IntegrityClient Need Sub: Physiological AdaptationNursing/Integrated Concepts: Nursing Process: ImplementationLearning Outcome: 24-2Question 13Type: MCSAA patient with a spinal cord injury is recovering from spinal shock. The nurse realizes that the patient should not develop a full bladder because what emergency condition can occur if it is not corrected quickly?1Global Rationale: Cognitive Level: ApplyingClient Need: Safe Effective Care EnvironmentClient Need Sub: Safety and Infection ControlNursing/Integrated Concepts: Nursing Process: AssessmentLearning Outcome: 24-5