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Question 31Type: MCMAA patient with a spinal cord injury (SCI) has a nursing diagnosis of Risk for Ineffective Tissue Perfusionrelated to the effects of neurogenic shock.The nurse includes which intervention in the patient's plan of care?Note: Credit will be given only if all correct choices and no incorrect choices are selected.Standard Text: Select all that apply.1. Fit the patient for an abdominal binder and thigh-length compression stockings.2. Monitor administration of atropine and other vasoactive agents as ordered or by protocol.3. Administer anticoagulant medication as ordered.4. Measure and record the diameter of the calf every shift.5. Measure and record intake and output.Correct Answer: 1,2,5
Rationale 1: Use of an abdominal binder and thigh-high compression stockings will help venous blood return and minimize blood pooling in the abdomen and lower extremities.Rationale 2: Vasoactive agents will support blood pressure and heart rate, thereby having a positive effect on cardiac output.Rationale 3: Anticoagulant medications will not reverse the cardiovascular effects of neurogenic shock.Rationale 4: Measuring the diameter of the calves is an intervention associated with treatment of deep vein thrombosis.Rationale 5: Measuring and recording intake and output will help assess fluid volume status. Dehydration reduces tissue perfusion.Global Rationale: Cognitive Level: ApplyingClient Need: Physiological IntegrityClient Need Sub: Physiological AdaptationNursing/Integrated Concepts: Nursing Process: PlanningLearning Outcome: 24-4Question 32Type: MCMARisk for Constipation related to impaired gastric motility is added to the nursing care plan of a patient with a new spinal cord injury (SCI). The nurse would plan which interventions to address this diagnosis?Note: Credit will be given only if all correct choices and no incorrect choices are selected.Standard Text: Select all that apply.