For which client conditions would the emergency department nurse stabilize the cervical spine as the priority nursing intervention quizlet?

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1. What populations are at highest risk for falls while in the emergency department?

ANS: Older adults, patients with delirium or dementia, and those who may be under the influence of alcohol or drugs (prescribed or illicit) are at the highest risk for falls.

2. What specific interventions can nurses implement to decrease falls?

ANS: Implement fall prevention strategies consistent with the facility's directives; assure clear pathways; ensure that patients who are fall risks have an identifying arm band; maintain regular safety precautions (e.g., bed placed into lowest position); delegate and supervise UAPs to sit with patient who is at highest risk for falls; communicate fall prevention strategies to patients and caregivers; use gait belt when ambulating or transferring; provide distraction activities that do not require ambulation.

3. What actions can be appropriately delegated to unlicensed personnel to decrease fall risk?

ANS: Sit with patient who is at highest risk for falls; assist patients during transfers and to/from bathroom; clear pathways.

4. How can the nursing staff reduce the risk for falls for patients who are confused (from dementia, medication side effects, or delirium)?

ANS: See answers to #2; all of these strategies can be implemented for any patient who is at risk for falls.

Disclaimer: These questions are typed by hand directly from Pearson and other study sources. I try hard to be sure that all of the information here is accurate, but I'm human and DO make mistakes, so please do your own research and never rely 100% on someone's Quizlets to get you through an exam- study! study! study!

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Which condition is an indication for decompression surgery for. client with spinal cord injury (SCI)? SATA
A) Cervical fracture without major cord damage
B) Progressive neurologic deterioration
C) Spinal nerve compression
D) Spinal stabilization
E) Facet dislocation

B, C, E

Rationale:
Spinal decompression surgery is most often performed in clients with progressive neurologic​ deterioration, facet dislocation​ (displacement of one vertebra on​ another), spinal nerve​ compression, and extradural lesions.

The nurse admitting a client who was in a motor vehicle crash is concerned that the client has an SCI with spinal shock. Which assessment finding would cause this concern? SATA
A) Warm, flushed skin
B) Hypertension
C) Flaccid paralysis
D) Urinary incontinence
E) Complete loss of sensation

C, D, E

Rationale:
Flaccid paralysis is an expected finding during spinal shock. The client will develop spastic movements later as edema from the initial injury resolves. Complete loss of sensation is common during spinal shock. This loss occurs because of edema in the area of the injury. Some sensation may return as the edema resolves. Low blood pressure occurs during spinal shock caused by lack of vasoconstriction needed to maintain blood pressure. This lack occurs because of damage to the nerve supply to the peripheral blood vessels. Incontinence occurs because of damage to the nerves that supply the bladder. This may or may not be permanent depending on the extent of the damage. Spinal shock causes an inability to regulate body temperature. The​ client's body will assume a temperature similar to the temperature of the environment. The​ client's skin would not be warm and flushed because of poor perfusion and low blood pressure during spinal shock

Possible exam question
The nurse is caring for a client diagnosed with a sensory incomplete SCI. The client asks the nurse to explain the injury. Which explanation should the nurse give?
A) Only sensory function will be present below the level of the injury
B) Only half of the muscles below the level of injury will function
C) No sensory or motor function will be present below the level of injury
D) Only motor function will be present below the level of the injury

A) Only sensory function will be present below the level of the injury

Rationale:
American Spinal Injury Association​ (ASIA) Impairment Scale​ (AIS). A​ = Complete: No sensory or motor function is preserved in the sacral segments
S4-S5.
B​ = Sensory​ incomplete: Sensory but not motor function is preserved below the neurologic level and includes the sacral segments
S4-S5
​(light touch, pin prick at
S4-​S5,
or deep anal​ pressure), AND no motor function is preserved more than three levels below the motor level on either side of the body. C​ = Motor​ incomplete: Motor function is preserved below the neurologic​ level, and more than half of key muscle functions below the single neurologic level of injury​ (NLI) have a muscle grade of less than 3​ (grades
0-​2).
D​ = Motor​ incomplete: Motor function is preserved below the neurologic​ level, and at least half of key muscle functions below the NLI have a muscle grade
≥3.
E​ = Normal: If sensation and motor function as tested with the International Standards for Neurologic Classification of Spinal Cord Injury​ (ISNCSCI) exam are graded as normal in all​ segments, and the client had prior​ deficits, then the AIS grade is E. Someone without an initial spinal cord injury​ (SCI) does not receive an AIS grade.

The nurse is discussing risk factors for SCI with a community group. Which group should the nurse include as being high risk for this type of injury?
A) Asian American
B) Older adult woman
C) Hispanic
D) Single young adult man

D) Single young adult man

Rationale:
Single young men are the individuals who are most likely to engage in risky​ behavior, such as diving into a​ too-shallow pool, not wearing protective gear while engaging in​ sports, or driving at high speeds.​ Non-Hispanic Caucasian Americans have the highest rates when race is​ compared, followed by​ non-Hispanic African​ Americans, Asian​ Americans, and American Indians.

Possible exam question
A client with a spinal cord injury has no movement or sensation in the left side of their body. Which term does the nurse use to describe this condition?
A) Tetraplegia
B) Quadriplegia
C) Hemiplegia
D) Paraplegia

C) Hemiplegia

Rationale:
Hemiplegia is paralysis of​ one-half of the body when it is divided along the median sagittal plane. Quadriplegia is partial or complete paralysis of the upper extremities and complete paralysis of the lower extremities. Paraplegia is paralysis of the lower part of the body. Quadriplegia is a synonym for tetraplegia.

The nurse is planning care for a client with a complete lumbar SCI. Which problem diagnosis should the nurse expect? SATA
A) Urinary Incontinence, Functional
B) Skin Integrity, Risk for Impaired
C) Aspiration, Risk for
D) Breathing Pattern, Ineffective
E) Self-care Deficit

A, B, E

Rationale:
The client is experiencing a lumbar spinal cord​ injury, which affects the lower​ limbs, back, and abdomen. When planning care for this​ client, the nurse needs to identify the following​ problems: impaired urinary​ elimination, risk for skin​ breakdown, and​ self-care deficits. Since the injury does not affect the diaphragm and chest​ area, impaired breathing patterns and risk of aspiration do not apply to this client.​ (NANDA-I ©​ 2014)

The nurse is caring for a pregnant woman who has a history of a complete L1 SCI. The client asks the nurse how to understand the onset of labor. Which is the nurse's correct response?
A."You will have to have a cesarean birth since your uterus cannot​ contract."
B."You will definitely feel the cramping pain with​ contractions."
C."You will have to be induced so that delivery is​ controlled."
D."You will need to watch for other symptoms of labor since you may not feel labor​ pains."

D) "You will need to watch for other symptoms of labor since you may not feel labor pains."

Rationale:
Pregnant women with decreased sensation in the lower trunk may not feel the typical pains of​ labor, so they should be taught the common signs of labor such as changes in​ breathing, abdominal​ tightening, and backache. Many women do not feel the labor​ pains, but do not necessarily need to be induced and may deliver vaginally.

The nurse is caring for a 76-year-old client is teaching home safety strategies prior to discharge. Which strategy should be taught to prevent the most common type of SCI in the older adult population?
A) Using assistive devices such as a cane when needed for stability
B) Having a system for family or neighbors to make daily checks
C) Participating in an emergency response system if living alone
D) Wearing seatbelts at all times while in moving vehicle

A) Using assistive devices such as a cane when needed for stability

Rationale:
Falls are the most common cause of SCI injury in the older adult population.​ Therefore, a teaching strategy to prevent falls is indicated. Wearing seat​ belts, having daily​ checks, and participating in an emergency response system are important for safety in the older adult but will not prevent falls. Using assistive devices can help prevent falls.

A client with a T4 SCI calls the nurse to the room for bowel incontinence. The client cries, "I am so sick of this! Why is this happening to me? I just give up!" Which nursing diagnosis is the priority?
A) Grieving
B) Mobility: Physical, Impaired
C) Skin Integrity, Impaired
D) Self-care Deficit, Toileting

A) Grieving

Rationale:
This client is experiencing a common emotional reaction to an
SCI—grief.
This should be addressed​ immediately, and emotional support should be given. ​Self-care Deficit:​ Toileting; Mobility:​ Physical,
Impaired​;
and Skin
Integrity​,
Impaired are all important to​ address, but the​ client's grief needs to be addressed first.​ (NANDA-I ©​ 2014)

The nurse is caring for a client with a C3 spinal cord injury who has diminished respiratory muscle control. Which intervention should the nurse include to promote adequate ventilation? SATA
A) Maintaining cervical alignment during intubation or airway insertion
B) Teaching the client to breathe deeply and cough every 2 hours
C) Implementing a scheduled bowel program
D) Encouraging frequent use of an incentive spirometer
E) Providing cough-assist treatments

B, D, E

Rationale:
With diminished muscle​ control, the client is at risk for atelectasis and pneumonia. Teaching coughing and deep​ breathing, using an incentive​ spirometer, and providing​ cough-assist treatments will aid in clearing lungs of secretions. Although maintaining cervical alignment is important if inserting an airway or​ intubating, this is actually done to prevent further spinal damage. A bowel program is implemented to prevent constipation.

A client with an SCI is scheduled to receive a high dose of methylprednisolone. Which reason does the nurse recognize for administering this medication?
A) To treat the acute pain of the traumatic injury
B) To reduce muscle spasticity
C) To prevent DVT and pulmonary embolism
D) To decrease inflammation and reduce damage to surrounding nerve cells

D) To decrease inflammation and reduce damage to surrounding nerve cells

Rationale:
Methylprednisolone in large doses is given to decrease inflammation and reduce damage to surrounding nerve cells. The acute pain of traumatic injury is treated with opioids. To prevent DVT and pulmonary​ embolism, heparin and warfarin​ (Coumadin) are administered. Muscle relaxants are given to reduce muscle spasticity.

The nurse working in the ER receives a client involved in a boating accident. Which should be the nurse's priority care for this client?
A) Preventing spinal shock
B) Preventing movement that could cause more damage
C) Realigning the spine with an emergency brace or traction
D) Maintaining the ability to breathe

D) Maintaining the ability to breathe

Rationale:
Maintaining an airway is the priority for care in emergent situations. Once the airway has been established and​ stabilized, the priority would be preventing​ movement, preventing​ shock, and then stabilizing the spine with a brace or traction.

The nurse is teaching a client with an SCI. Which information should the nurse provide to help the client avoid autonomic dysreflexia? SATA
A) Avoid excessive exposure to the sun
B) Wear tight-fitting clothes
C) Change positions frequently when sitting in a chair
D) Consume a low-fiber diet
E) Monitor urine for color and oder

A, C, E

Rationale:
When teaching a client about ways to avoid autonomic​ dysreflexia, the client needs to consume a​ high-fiber diet with adequate fluid to prevent constipation. The client also needs to monitor urine for color and odor. If the client experiences manifestations of a urinary tract​ infection, it must be treated immediately. The client needs to be instructed to wear​ loose-fitting clothes and to change positions frequently when sitting in the chair or when in bed. A client with a spinal cord injury should also avoid sunburn because it can lead to autonomic dysreflexia.

Which client is most at risk for developing respiratory difficulty?
A) A client with an injury at L5
B) A client with an injury at T6
C) A client with an injury at S2
D) A client with an injury at T15

B) A client with an injury at T6

Rationale:
Clients with injuries above T12 will experience some decrease in respiratory muscle​ control; the higher the level of​ injury, the more severe the deficiencies.

Which nonpharmacologic intervention should the nurse implement to prevent the development of a DVT in a client who has tetraplegia?
A) Providing passive ROM
B) Encouraging foods that are high in protein
C) Administering subcutaneous heparin
D) Implementing incentive spirometery

A) Providing passive ROM

Rationale:
Providing passive ROM is a nonpharmacologic therapy that will help to promote venous circulation and decrease the risk of development of DVT. A diet high in protein would be indicated if a pressure wound develops to promote healing. Anticoagulants may be administered but are a pharmacologic intervention. The use of an incentive spirometer is a nonpharmacologic treatment used to help prevent​ pneumonia, not DVT.

The nurse on the med-surg unit is providing care for a client with a cervical SCI from an accident several years ago. The client reports a headache. The client's BP is 230/115. which intervention should the nurse provide? SATA
A) Checking the client's bladder
B) Removing the client's compression stockings
C) Checking the client for bowel impaction
D) Rechecking the BP in 2 hours
E) Administering acetaminophen (Tylenol)

A, B, C

Rationale:
The client has manifestations of autonomic dysreflexia. This is a medical emergency. A distended urinary bladder can cause autonomic dysreflexia. If the bladder is causing the​ problem, the nurse can relieve manifestations by draining the​ client's bladder. A distended bowel can cause autonomic dysreflexia. If the bowel is the​ problem, the nurse can relieve the manifestations by removing the impaction. The compression stockings can contribute to autonomic dysreflexia by creating an irritation that causes the manifestations. The stockings also elevate blood pressure by increasing venous return to the heart. Rather than rechecking the blood pressure every 2​ hours, the nurse would continue to look for the cause until it is found and corrected. Administering acetaminophen would not address the manifestations of autonomic dysreflexia.

Which nursing goal would be appropriate for a client who has a C2 SCI with resolving pneumonia?
A) The client will require deep suctioning no more than every 2 hours
B) The client will maintain oxygen saturation less than 95%
C) The client will have ABGs within normal limits
D) The client will remain free of symptoms of autonomic dysreflexia

C) The client will have ABGs within normal limits

Rationale:
An appropriate goal for the client with resolving ventilation complications would be to have ABGs within normal limits. Oxygen saturations should be maintained at greater than​ 95%. The client should no longer require deep suctioning. Autonomic dysreflexia is an unrelated complication of pneumonia.

When reviewing the medical record of a client who experienced an SCI, the nurse notes that the client experienced the injury while diving into shallow water. Which type of excessive force does the nurse consider to have been placed on the vertebral column?
A) Hyperflexion
B) Transection
C) Compression
D) Hyperextension

C) Compression

Rationale:
Compression occurs when excessive vertical force is applied to the spinal​ cord, such as in a diving accident. Transection of the spinal cord occurs when a force partially or completely severs the spinal cord. Excessive force in which the neck is forced backwards is hyperextension and is seen in whiplash injuries. Hyperflexion occurs when excessive force forces the head forward onto the chest.

The nurse is developing a plan of care for a client with urinary retention related to a flaccid bladder. Which intervention should the nurse include? SATA
A) Maintaining in semi-Fowler's position
B) In and out catheterization as indicated
C) Limiting fluid intake
D) Beginning bladder training
E) Assessing bladder volume

B, D, E

Rationale:
A client who has a flaccid bladder will need assistance with bladder emptying to avoid bladder​ overdistention, bladder and kidney​ infection, and the development of kidney stones. Bladder training is possible in many clients depending on the level of the injury. Fluid should not be​ withheld, as dehydration can lead to other complications. Bladder volume should be assessed and catheterization performed as indicated.​ Semi-Fowler's position is not indicated.

An emergency department nurse receives a client who reportedly has a C1 complete SCI. Which collaborative intervention should the nurse immediately prepare for the client?
A) Reflex testing
B) Endotracheal intubation
C) Assessment using the muscle function grading scale
D) American Spinal Injury Association (ASIA) Impairment Scale scoring

B) Endotracheal intubation

A client with an SCI at level C3 or higher loses control of all four muscle groups needed for breathing. These individuals require immediate ventilator support. Muscle function​ grading, ASIA Impairment Scale​ scoring, and reflex testing should be done after the client is stabilized.

An adolescent is brought into the emergency department (ED) with injuries sustained from a motor vehicle crash. What is a priority while providing nursing care for this client?
A) Adequate urine output
B) Stable blood pressure
C) Continued stabilization of the neck and spinal cord
D) Insertion of an intravenous access line

C) Continued stabilization of the neck and spinal cord

rationale:
The danger of death from a spinal cord injury is greatest when there is damage to or transection of the upper cervical region. All people who have sustained trauma to the spine should be treated as though they have a spinal cord injury by stabilizing the neck and spinal cord. Assessment of urine output can be delayed. Assessing blood pressure is an intervention for all clients brought into the emergency department. An intravenous access line is necessary, but stabilization of the neck and spinal cord is of first priority.

A school nurse is treating a school-age client who has fallen down a flight of stairs. The client is breathing but unconscious. After calling the ambulance, which is the priority action by the nurse?
A) Open the airway using the head tilt maneuver.
B) Try to rouse the client by gently shaking the shoulders.
C) Protect the client's neck and head from any movement.
D) Place the client on the side to prevent aspiration

C) Protect the client's neck and head from any movement

Rationale:
Guidelines for emergency care are avoiding flexing, extending, or rotating the neck; immobilization of the neck; securing the head; maintaining the client in the supine position; and transferring the client from the stretcher to the hospital bed with backboard in place. This client is unconscious, and the nurse must protect the neck from any (or any further) damage. If the client vomits, the nurse should use the log-roll technique to turn the client while keeping the head, neck, and spine in alignment. This client is breathing; however, if a change in respirations were to occur, the airway should be opened using the jaw thrust maneuver. Rousing the client by shaking could cause damage to the spinal cord.

A client who sustained a cervical neck injury 2 days ago is demonstrating an irregular respiratory pattern with a rate of 8-10 breaths per minute. Based on this data, which is the priority nursing diagnosis?
A) Impaired Physical Mobility
B) Autonomic Dysreflexia
C) Ineffective Breathing Pattern
D) Impaired Gas Exchange

C) Ineffective breathing pattern

Rationale:
Because the client sustained the neck injury 2 days prior, the full extent of the injuries cannot yet be determined. The client's rate of respirations should be between 12 and 20 breaths per minute. Because the client is breathing irregularly at a rate of 8-10 breaths per minute, the client may need assisted ventilation or a tracheostomy. The priority nursing diagnosis for this client would be Ineffective Breathing Pattern. A diagnosis of Impaired Gas Exchange could occur because of the Ineffective Breathing Pattern diagnosis, but it would be the second in priority for this client. The diagnoses of Impaired Physical Mobility and Autonomic Dysreflexia could both be addressed at a later time.

The nurse is planning care for a client admitted with a high thoracic spinal cord injury. Which interventions would be appropriate for the nursing diagnosis of Ineffective Peripheral Tissue Perfusion? SATA
A) Discuss future care needs when the client is discharged.
B) Increase fluids to 3000 mL per day.
C) Turn and reposition the client every 2 hours.
D) Assess for a full bladder.
E) Assess blood pressure every 2-3 minutes.

D, E

Rationale:
Ineffective perfusion can be caused by autonomic dysreflexia, which is an emergency that requires immediate assessment and intervention. The nurse should continue to assess the client's blood pressure every 2-3 minutes in addition to elevating the head of the bed and removing tight clothing to encourage the pooling of blood in the extremities and decrease the blood pressure. Once the client's blood pressure has stabilized or decreased, the nurse can then assess for the stimuli that caused the episode, such as a full bladder. Discussing future care needs when discharged is not a priority at this time, nor is it an intervention for Ineffective Peripheral Tissue Perfusion. Turning the client every 2 hours is not a priority at this time, nor is it an intervention for Ineffective Peripheral Tissue Perfusion.

The nurse is evaluating the effectiveness of interventions to address a client's bowel and bladder dysfunction as a result of a spinal cord injury. Which finding would indicate that these interventions have been successful?
A) The client had two episodes of impacted stool over the last week.
B) The client is improving in ability to perform self-urinary catheterization.
C) The client is limiting fluids to reduce need to void.
D) The client has an indwelling urinary catheter and is provided with stool softeners every morning.

B) The client is improving in ability to perform self-urinary catheterization

Rationale:
An ideal outcome for the client with bowel and bladder dysfunction as a result of a spinal cord injury would be for the client to attain appropriate bowel and bladder elimination habits. If the client's ability to perform self-urinary catheterization is improving, the interventions can be considered successful. A client with an indwelling urinary catheter who is receiving stool softeners every morning is not progressing toward appropriate bowel and bladder elimination habits. A client who had two episodes of impacted stool over the last week is not progressing in bowel elimination habits. A client who is limiting fluids to reduce the need to void is possibly hindering his health in order to avoid having to perform self-urinary catheterization.

Possible Exam Question
The nurse in the emergency department is preparing to administer methylprednisone to a client with a spinal cord injury. What does the nurse recognize as the intended therapeutic effect of the medication?
A) To increase blood glucose level
B) To improve the client's level of consciousness
C) To prevent cord damage from ischemia and edema
D) To improve the client's ability to be adequately ventilated

C) To prevent cord damage from ischemia and edema

Rationale:
High-dose steroid protocol using methylprednisone must be implemented within 8 hours of spinal cord injury to improve neurologic recovery. Clinical research indicates that use of this medication is effective in preventing secondary spinal cord damage from edema and ischemia. Methylprednisone may cause hyperglycemia if the client also has a diagnosis of diabetes. This medication is not provided to improve respirations or improve the level of consciousness.

The nurse is evaluating the success of a bowel and bladder retraining program with a client who is recovering from a lower motor neuron spinal cord injury. Which observations indicate that this teaching has been successful? SATA
A) One episode of bladder incontinence in 8 hours
B) Client performs self-urinary catheterization every 4 hours while awake
C) Client transfers to use bedside commode after breakfast to evacuate bowels
D) Two episodes of impacted stool in 1 week
E) Client maintains a high-fluid, high-fiber diet

B, C, E

Rationale:
Evidence that a bowel and bladder retraining program for a client with a spinal cord injury has been successful includes the client performing self-urinary catheterization every 4 hours while awake, transferring to the bedside commode to evacuate bowels after breakfast, and maintaining a high-fluid and high-fiber diet to prevent constipation. Evidence that this training has not been successful includes an episode of bladder incontinence and the need to have impacted stool removed twice in 1 week.

The nurse is caring for a client who sustained a gunshot wound below the level of T12, resulting in ipsilateral motor paralysis, ipsilateral loss of proprioception and vibratory sense, and contralateral loss of pain and temperature sensation. When planning care for this client, which interpretations of this data by the nurse are likely to be correct? SATA
A) The client's American Spinal Injury Association Impairment Scale score is A.
B) The spinal cord injury is incomplete.
C) These findings are consistent with Brown-Sequard syndrome.
D) Hemisection of the spinal cord is likely.
E) Some recovery of sensory function is likely.

B, C, D, E

Rationale:
Hemisection of the spinal cord, usually caused by a penetrating trauma (gunshot, knife), causes sensory and motor deficits on opposite sides of the body because the spinal cord injury is incomplete. These findings are consistent with Brown-Sequard syndrome, which has the best prognosis of all the incomplete spinal cord syndromes. An American Spinal Injury Association (ASIA) Impairment Scale (AIS) score of A indicates a complete spinal cord injury where no sensory or motor function is preserved in the sacral segments S4-S5.

The nurse is presenting a talk on spinal cord injury for a community health fair. Which statement on the part of the attendees indicates that they understand the risk factors and prevention methods associated with spinal cord injury?
A) "There isn't much I can do to prevent a head injury when another vehicle hits my car."
B) "As long as my grandson wears a helmet, he will be safe on his motorcycle."
C) "I'm going to spend extra time discussing this talk with my college-age son because of his higher risk for spinal cord injury."
D) "Due to their elevated risk, I'd like you to present this talk to members of the local Native American population."

C) "I'm going to spend extra time discussing this talk with my college-age son because of his higher risk for spinal cord injury."

Rationale:
The highest-risk population for spinal cord injuries is young adult males, including college-age men. Riding motorcycles increases the risk of spinal cord injuries, even when helmets are used. Native Americans are the ethnic group with the lowest risk of spinal cord injury. Using a seat belt is a major preventive action for individuals who are involved in motor vehicle crashes.

The nurse assesses a young adult client who was involved in a swimming accident that resulted in tetraplegia. The client makes eye contact with the nurse and states, "I'm going to beat this and walk out of here." Based on this statement, which nursing diagnosis is most appropriate for this client?
A) Risk for Post-Trauma Syndrome
B) Impaired Physical Mobility
C) Self-Care Deficit
D) Noncompliance

A) Risk for Post-Trauma Syndrome

Rationale:
The client's statement is unrealistic and evidence of Risk for Post-Trauma Syndrome. Although the diagnoses of Impaired Physical Mobility and Self-Care Deficit are appropriate for a client with tetraplegia, this statement is not evidence of those nursing diagnoses. There is no indication of Noncompliance.

A female client who sustained a spinal cord injury (SCI) several years ago tells the nurse she is interested in becoming pregnant. She asks the nurse for more information about how her SCI might impact a potential pregnancy. Which of the following statements should the nurse include in her response to the client?
A) "Women with SCI should avoid pregnancy, because it puts too much stress on their bodies and can exacerbate their injuries."
B) "If you become pregnant, your risk for autonomic dysreflexia will likely decrease."
C) "The good news is that none of the medications used in the treatment of SCI are known to have detrimental effects on the fetus."
D) "Should you have a baby and opt to breastfeed, you may experience an increase in muscle spasticity."

D) "Should you have a baby and opt to breastfeed, you may experience an increase in muscle spasticity."

Rationale:
Women with SCI are considered to be "high risk" during pregnancy, but that does not mean pregnancy should be avoided. Instead, the woman will need to work closely with a team of healthcare professionals to prevent complications and prepare for pregnancy, labor, and delivery. Pregnant women are at higher risk for autonomic dysreflexia, especially during labor and delivery. Many women are unable to continue taking prescribed medications during pregnancy due to the potential harm they pose to the fetus. New mothers must also consider the effects of their SCI on breastfeeding; muscle spasticity may increase during breastfeeding, and women with limited sensation in their breasts may have reduced milk production.

Possible exam question
A client with permanent paralysis of the trunk, arms, and legs would be said to be experiencing which of the following conditions?
A) Tetraplegia
B) Paraplegia
C) Spinal shock
D) Complete spinal cord injury (SCI)

A) Tetraplegia

Rationale:
Tetraplegia (also called quadriplegia) is paralysis of the upper and lower limbs and trunk. Paraplegia is paralysis of all or part of the trunk, legs, and pelvic organs. Spinal shock is a temporary condition characterized by spinal cord swelling; decreased blood flow and blood pressure; and complete loss of motor function, spinal reflexes, and autonomic function below the level of injury. Complete SCIs involve a total loss of all sensory and motor function below the level of the injury. Depending on its location, a complete SCI could results in either tetraplegia or paraplegia.

Which client should the nurse consider to need the highest priority care?

Which nursing intervention is the priority for a client with stroke who is transitioned from the emergency department to other settings?

Which level of emergency severity index would be considered the lowest priority in the emergency department?

Which nursing skill is essential for the triage process in the emergency department ED )?