An adolescent recovering from a spinal cord injury calls out for ...

[Cooldude101]

An adolescent recovering from a spinal cord injury calls out for help. The patient's face is bright red, and the patient is experiencing a severe headache. What is the first thing that the nurse should do for this patient?
 
  A) Administer mouth-to-mouth resuscitation.
  B) Assess if the urinary retention catheter is blocked.
  C) Massage the lower extremities to cause vasodilation.
  D) Lower the head of the bed to increase cerebral circulation.

Question 2

The nurse is caring for a 10-year-old boy who is in traction.
 
  The boy has a nursing diagnosis of deficient diversional activity related to confinement in bed that is evidenced by verbalization of boredom and lack of participation in play, reading, and schoolwork. Which of the following would be the best intervention? A) Offer the child reading materials.
  B) Enlist the aid of a child life specialist.
  C) Encourage the child to complete his homework.
  D) Ask for the parents' assistance.

[bblaney]

Answer to Question 1

B
Feedback:
The patient is demonstrating signs of autonomic dysreflexia, which include extreme hypertension, tachycardia, flushed face, and severe occipital headache. This can occur if the patient's bladder is allowed to fill. The resultant sensory stimulation relayed to the damaged cord can initiate a powerful sympathetic reflex reaction. The nurse should assess that the patient's urinary catheter is not obstructed, so urine can flow freely and reduce the sensory stimulation. The patient is talking, so mouth-to-mouth resuscitation is not necessary. Massaging the lower extremities and lowering the head of the bed will not relieve the sensory stimulation caused by the blocked urinary catheter.

Answer to Question 2

B
Feedback:
The nurse should enlist the aid of a child life specialist to provide suggestions for appropriate activities. Offering the child reading materials or encouraging him to complete his homework would most likely be met with resistance as he has already verbalized his boredom and disinterest in play, reading, and schoolwork. The parents could offer the child life specialist ideas about the boy's likes and dislikes; however, the child life specialist could offer expertise in assisting hospitalized children.

[Cooldude101]

Excellent

[kusterl]

TYSM