The nurse is working with a client with a spinal cord injury and ...

[jho37]

The nurse is working with a client with a spinal cord injury and an indwelling urinary catheter. Maintaining patency of the catheter is critical to avoid autonomic dysreflexia from an extended bladder.
 
  The nurse is alerted to this complication if the client experiences: A. Pallor
  B. Skin dryness
  C. Hypotension
  D. Bradycardia

Question 2

A nonpharmacological approach that the nurse may implement for patients who are experiencing pain that focuses on diverting the patient's attention away from the pain sensation by promoting pleasurable and meaningful stimuli is:
 
  a. massage.
  b. heat/cold.
  c. guided imagery.
  d. distraction.

[jaymee143]

Answer to Question 1

D
D. Client with a spinal cord transection experiences the following symptoms: blood pressure (BP) elevated to 200 mm Hg systolic, bradycardia, headache, flushing and sweating above the spinal level of the injury. Spinal cordinjured (SCI) clients run the risk of autonomic dysreflexia (hyperreflexia) when exposed to a noxious stimulus such as a full bladder.
A, B, and C. These are indicators of possible dehydration.

Answer to Question 2

D
Distraction is a technique that diverts an individual's attention away from the pain sensation. By introducing meaningful stimuli, the nurse helps the patient refocus attention. Distraction directs a patient's attention to something else and thus can reduce awareness of pain and even increase tolerance. A proper massage not only blocks the perception of pain impulses but also helps relax muscle tension and spasm that otherwise might increase pain. Massage hastens the elimination of wastes stored in muscles, improves oxygenation of tissues, and stimulates the relaxation response in the nervous system. Heat produces vasodilation, reduced blood viscosity, reduced muscle tension, and increased tissue metabolism. Heat helps relieve muscle spasms and joint stiffness. Cold produces vasoconstriction, reduced cell metabolism, and increased blood viscosity. Cold is effective for inflamed joints and muscles. The goal of imagery is to have the patient use one or several of the senses to create an image of the desired result. This image creates a positive psychophysiological response. Guided imagery can be used as a distraction technique.

[jho37]

TY

[jaymee143]

You're welcome