HESI Case Studies–Medical/Surgical-Spinal Cord Injury (Jonathan Begay) – Flashcards
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1. What should Jonathan's friends do while waiting for emergency personnel to arrive? (Select all)
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-Place blanket over Jonathan and make sure no one moves him -Ensure that the scene around Jonathan is safe and that he is not in any immediate danger
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2. If respiratory compromise occurs, what action should the nurse take to keep the airway open without compromising Jonathan's spine further?
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Perform the jaw-thrust technique
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3. Which intervention has highest priority when assessing Jonathan?
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Assess Jonathan's breathing pattern and his ability to cough
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4. Which assessment data warrants immediate intervention by the ED RN? (Select all)
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-Jonathan complains of a loss of sensation below his shoulders. His skin is flushed and warm to touch, particularly in the extremities -Jonathan's blood pressure is 88/48, and his pulse is 50 -Jonathan appears to have bladder distention
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5. What intervention should the nurse implement first?
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Notify the ED healthcare provider (HCP) immediately
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6. What medication(s) should the ED RN expect the HCP to prescribe for Jonathan? (Select all)
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-Methylprednisolone sodium succinate, a corticosteriod -Dopamine, a vasopressor
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7. Methylprednisolone Sodium Succinate (Solu-Medrol), is prescribed as 125 mg intravenous piggy back (IVPB) over 30 minutes. The IVPB containing the medication contains 100 mL of fluid. The drop factor on the IV tubing is10 gtts/min. How many drops/min (gtts/min) should the nurse regulate the IVPB? (If applicable, round to the whole number)
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33
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8. Which nursing intervention is included in the care plan when managing a client with Gardner-Wells tongs?
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Do not remove the traction weights and ensure they hang freely
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9. Which intervention should be implemented for a paralytic ileus?
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Insert a nasogastric tube and set the siphon drainage to a low, intermittent suction
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10. Which intervention(s) should the RN implement to address this concern? (Select all)
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-Allow Jonathan to watch television as much as he likes -Encourage Jonathan's girlfriend to talk to him during visits -Provide Jonathan prism glasses, and tell him how to use them
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11. Which nursing diagnosis has priority at this time?
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Risk for impaired skin integrity
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12. Which outcome should the RN use for evaluation of the efficacy of interventions designed for this nursing diagnosis?
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The client exhibits no reddened areas or breaks in the skin
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13. According to the principle of veracity, how should the RN respond to Jonathan's question?
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"No Jonathan; it is unlikely that you will ever be able to walk again."
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14. Which intervention should the nurse implement?
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Arrange a meeting with Jonathan, his family, and the healthcare team to discuss Jonathan's concerns
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15. What is the best initial action by the nurse?
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Obtain more information about what the grandfather want to do
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16. How should the nurse respond to this statement?
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Sit quietly and allow the grandfather to continue
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17. Jonathon wants to know what a living will is. How should the nurse respond?
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"It is a legal document that helps us make decisions about your healthcare, based on you wishes."
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18. What is the best response by the nurse?
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"I am sorry, but I cannot share that information with you."
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19. Which psychosocial intervention by the nurse has priority at this time?
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Let Jonathan know that if he wants to talk or has questions, the RN is available to listen
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20. What action should the nurse implement at this time?
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Sit down beside Jonathan's mother
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21. Which information should the nurse include when discussing a bowel elimination program with Jonathon?
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Plan bowel evacuation at the same time every day
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22. Which statement by Jonathon indicates an understanding of autonomic dysreflexia?
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"I should empty my bladder at least every 2 to 3 hours."
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23. Which intervention should the nurse implement first?
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Move Jonathan to a sitting position
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24. Which intervention should the nurse implement to address disuse syndrome?
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Perform passive range of motion (ROM) exercises every 4 hours
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25. Which task can the nurse delegate to the UAP?
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Measure the intake and output for the client taking diuretics
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26. Which behavior by the UAP warrants immediate intervention by the RN?
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The UAP is feeding the client
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27. Which intervention should the RN implement first?
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Ask Jonathan if he would like to share his fears about life after leaving the hospital
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28. Which action should RN implement
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Refer Jonathan to a local counselor for vocational rehabilitation
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29. Which intervention will the RN include when discussing ways to prevent muscle spasticity
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Perform stretching exercises five to seven times each day
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30. Which statement made by Jonathan's mother indicate that she understands bladder care for jonathan
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"I should remove the condom catheter nightly to clean his penis."
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31. Which member of the rehab multidisciplinary team is responsible for ensuring that Jonathan will be discharged to a home that is equipped with care for him?
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The occupational therapist
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32. Which area has priority according to Maslow's heirarchy of needs
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Instructions concerning ways to prevent urinary tract infections
