A nurse is caring for a patient with a spinal cord injury who is about to be transferred to a wheelchair for physical therapy.
The patient complains of feeling dizzy and is diaphoretic.
What would be the priority nursing action?

Establish IV access and bolus 250 mL of normal saline.

Reschedule the therapy session for later in the day.

Lower the head of the bed and obtain vital signs.

Assess for bladder distention and perform digital disimpaction.

Answer and Explanation

The Correct Answer is C

Choice A rationale

IV fluid bolus may address hypotension but is not the first priority. Symptoms of dizziness and diaphoresis in a spinal cord injury patient suggest autonomic dysreflexia or orthostatic hypotension requiring positional changes first.

Choice B rationale

Rescheduling therapy does not address the acute symptoms the patient is experiencing. Immediate action to manage dizziness and diaphoresis, such as altering body position, is required to stabilize the patient.

Choice C rationale

Lowering the head of the bed counters orthostatic hypotension, a common issue in spinal cord injury patients. Obtaining vital signs identifies the underlying cause and guides further interventions.

Choice D rationale

Bladder distention can trigger autonomic dysreflexia, but without evidence of urinary retention, prioritizing positional adjustments is more urgent to alleviate symptoms of dizziness and stabilize hemodynamics.

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Correct Answer is A

Explanation

Choice A rationale

Vigorous coughing or nose blowing increases pressure in the middle ear, potentially dislodging the stapes prosthesis, interfering with healing, and increasing risk of complications like vertigo or auditory damage.

Choice B rationale

Packing with dry dressing is contraindicated because it may trap moisture and increase infection risk. If drainage occurs, sterile measures are taken to assess and manage infection without creating ideal conditions for pathogens.

Choice C rationale

Irrigation of the ear canal risks introducing pathogens or disrupting the surgical area. Post-surgery, maintaining a dry environment helps reduce infection and promote proper healing.

Choice D rationale

Though bedrest may be recommended initially, prolonged immobility isn't essential unless specific complications arise. Movement minimizes risks of clot formation and encourages circulation, aiding recovery.

A. Scheduled voiding. B. External catheter. C. Indwelling urinary catheter. D. Intermittent catheterization.

Correct Answer is D

Explanation

Choice A rationale

Scheduled voiding relies on the patient’s ability to control bladder function, which is ineffective in cases of a flaccid bladder caused by spinal cord injuries.

Choice B rationale

External catheters, such as condom catheters, are suited for patients with partial bladder control but are not appropriate for flaccid or atonic bladder management.

Choice C rationale

Indwelling urinary catheters may be used short-term but pose higher risks of urinary tract infections and are not optimal for long-term management of flaccid bladder.

Choice D rationale

Intermittent catheterization is the preferred method for managing flaccid bladder, ensuring complete bladder emptying while minimizing infection risks compared to indwelling catheters.

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A nurse is caring for a patient with a spinal cord injury who is about to be transferred to a wheelchair for physical therapy.The patient complains of feeling dizzy and is diaphoretic.What would be the priority nursing action?

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A client has had a stapedectomy for otosclerosis 24 hours ago.What must the nurse teach the client about post-operative care?

Correct Answer is A

Explanation

The nurse is caring for a patient with a spinal cord injury who has a flaccid or atonic bladder.The nurse would provide discharge education to the patient and family regarding which bladder management technique?

Correct Answer is D

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A nurse is caring for a patient with a spinal cord injury who is about to be transferred to a wheelchair for physical therapy.
The patient complains of feeling dizzy and is diaphoretic.
What would be the priority nursing action?