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Note: Credit will be given only if all correct choices and no incorrect choices are selected.Standard Text: Select all that apply.1. Monitoring skin temperature in lower extremities2. Assessing for abdominal distention3. Bladder scan postvoiding4. Assessing pulse oximetry levels with vital signs5. Strict output monitoringCorrect Answer: 2,3,5Rationale 1: Monitoring lower-extremity skin temperature is appropriate for detecting deep vein thrombosis.Rationale 2: Causes of autonomic hyperreflexia are impacted stool or constipation, so assessing for abdominal distention is appropriate.Rationale 3: The nurse caring for spinal cord injury (SCI) patients should be attuned to the prevention of a distended bladder to prevent the chain of events that leads to autonomic hyperreflexia. Scanning the bladder postvoiding can detect residual urine retention.Rationale 4: Pulse oximetry is effective in monitoring for a decline in oxygen saturation and may be the initial indicator of a pulmonary embolus.Rationale 5: Tracking urinary output carefully can help detect residual urine retention.Global Rationale: Cognitive Level: AnalyzingClient Need: Physiological IntegrityClient Need Sub: Physiological AdaptationNursing/Integrated Concepts: Nursing Process: AssessmentLearning Outcome: 24-5Question 24
Type: MCSAA 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.Correct Answer: 4Rationale 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.Global Rationale: Cognitive Level: ApplyingClient Need: Physiological IntegrityClient Need Sub: Physiological AdaptationNursing/Integrated Concepts: Nursing Process: PlanningLearning Outcome: 24-3Question 25Type: MCSAA patient with a recent spinal cord injury is at risk for complications to the gastrointestinal system. Which nursing intervention is primarily directed at minimizing this risk?