The nurse is caring for a patient who suffered a spinal cord injury (SCI) who has had halo traction placed for spinal immobilization. What emergency equipment should the nurse have at the bedside? (SELECT ALL THAT APPLY)
Padded tongue blades to prevent injury in the event of seizure
Soft wrist restraints to prevent injury
Ambu bag and oxygen connection for respiratory distress
Wrenches for emergency removal of traction equipment
Oral suction tube (Yankaur) for secretion removal
Correct Answer : C,D,E
A. Padded tongue blades are not appropriate for seizure management and are not necessary in this context.
B. Soft wrist restraints are not required in this scenario unless otherwise indicated.
C. An Ambu bag and oxygen are crucial for respiratory support, especially if the patient has compromised breathing due to spinal cord injury.
D. Wrenches should be readily available to quickly remove halo traction in case of an emergency, such as if the patient's airway needs to be accessed.
E. An oral suction tube (Yankauer) is important for managing oral secretions, which can be challenging for patients with limited mobility.
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Related Questions
Correct Answer is C
Explanation
A. Chronic head injury patients often struggle with processing multiple pieces of information simultaneously due to cognitive limitations.
B. Activities requiring complex strategy, like chess, are typically challenging shortly after admission and not a realistic expectation.
C. Difficulty with planning and organizing thoughts and behaviors is a common cognitive deficit in patients with chronic head injury due to impaired executive function, often resulting from damage to the frontal lobe.
D. While non-compliance can occur, it is less predictable and may not be directly linked to chronic head injury itself.
Correct Answer is D
Explanation
A. Antibiotics may be necessary if infection is confirmed, but this is not the priority action.
B. Applying a pressure dressing could increase intracranial pressure or worsen the injury.
C. IV fluids can be helpful in managing shock but are not directly related to CSF leakage management.
D. Yellowish fluid from the ear, which creates a "halo" or yellow ring around it on gauze, may indicate cerebrospinal fluid (CSF) leakage. This is a sign of a potential skull fracture and requires prompt provider notification. Allowing the fluid to drain and collecting it can provide necessary information about the injury.
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