An adolescent has just returned from surgery after spinal fusion ...

[pane00]

An adolescent has just returned from surgery after spinal fusion surgery. Which of the following assessments would be priority at this time?
 
  1. Increased intracranial pressure
   2. Seizure activity
   3. Impaired pupillary response during neurological checks
   4. Impaired color, sensitivity, and movement to lower extremities

Question 2

A child must wear a brace for correction of scoliosis. Which of the following nursing diagnoses takes priority at this time?
 
  1. Impaired Skin Integrity, risk for
   2. Altered Growth and Development, risk for
   3. Impaired Mobility, risk for
   4. Impaired Gas Exchange, risk for

[SAUXC]

Answer to Question 1

4
Rationale:
1. Increased intracranial pressure is not a great risk following spinal fusion surgery. Impaired color, sensitivity, and movement to the lower extremities are greater risks.
2. Seizure activity is not typically seen following spinal fusion. There is a risk for impaired color, sensitivity, and movement to the lower extremities.
3. Pupillary response is not affected after spinal fusion surgery. There is a risk for impaired color, sensitivity, and movement to the lower extremities.
4. When the spinal column is manipulated, there is a risk for impaired color, sensitivity, and movement to lower extremities. The other signs are neurological impairment, and are not high-risk with spinal surgery.

Answer to Question 2

1
Rationale:
1. The skin should be monitored for breakdown in any area where the brace might rub against the skin.
2. The diagnosis of altered growth and development would not be the priority, and should be corrected by the wearing of the brace.
3. The diagnosis of impaired mobility would not be the priority, and should be corrected if the patient is compliant with wearing the brace.
4. Risk for impaired gas exchange is a late effect of scoliosis, and would not be the priority. If the patient is compliant with wearing the brace, the risk should be minimized.