1. A nurse in the emergency department is implementing a plan of care for a conscious client who has a suspected

cervical cord injury. Which of the following immediate interventions should the nurse implement? (Select all that

apply.)

A. Hypotension

B. Polyuria

C. Hyperthermia

D. Absence of bowel sounds

E. Weakened gag reflex

Rationale: Hypotension is correct. Lack of sympathetic input can cause a decrease in blood

pressure. The nurse should maintain the client's SBP at 90 mm Hg or above to adequately

perfuse the spinal cord.

Polyuria is incorrect. The nurse should check the

client for bladder distention and inability to urinate due to ineffective function of the bladder

muscles.

Hyperthermia is incorrect. The nurse should monitor the client for

hypothermia caused by a lack of lack of sympathetic input.

Absence of bowel

sounds is correct. Spinal shock leads to decreased peristalsis, which could cause the client

to develop a paralytic ileus.

Weakened gag reflex is correct. The nurse should

monitor the client for difficulty swallowing, or coughing and drooling noted with oral intake.

2. A nurse is performing discharge teaching for a client who has seizures and a new prescription for phenytoin. Which

of the following statements by the client indicates a need for further teaching?

A. "I will notify my doctor before taking any other medications."

Rationale: Many medication interactions can occur with phenytoin; therefore, the client's provider should be

notified that the client is taking phenytoin.

B. "I have made an appointment to see my dentist next week."

Rationale: The client understands that phenytoin causes an overgrowth of the gums that makes dental

monitoring important.

C. "I know that I cannot switch brands of this medication."

Rationale: The client understands that bioavailability varies with different brands, so no substitutions should

be made.

D. "I'll be glad when I can stop taking this medicine."