A nurse developing a plan of care for a client with a spinal cord injury includes measures to prevent autonomic dysreflexia (hyperreflexia). Which intervention does the nurse incorporate into the plan to prevent this complication?

a. Keeping the fan running in the client's room

b. Keeping the linens wrinkle free under the client

c. Limiting bladder catheterization to once every 12 hours

d. Avoiding the administration of enemas and rectal suppositories

B

The most frequent cause of autonomic dysreflexias are a distended bladder and impacted feces. Other causes include stimulation of the skin by tactile, thermal, or painful stimuli. The nurse renders care in such a way as to minimize these risks.

A nurse provides home care instructions to a client who has been fitted with a halo device to treat a cervical fracture. Which statement by the client indicates the need for further teaching?

a. I need to get more fluids and fiber into my diet

b. I should cut my food into small pieces before I eat

c. I need to put powder under the vest twice a day to prevent sweating

d. I have to check the pin sites everyday and watch for signs of infection

C

Cleanse the skin under the wool liner each day to prevent rashes and soars.

A nurse is caring for a client with increased intracranial pressure. In which position should the nurse maintain the client?

a. Supine with the head extended

b. Side lying with the neck flexed

c. Supine with the head turned to the side

d. Head midline and elevated 30-45 degrees

D

Proper positioning promotes venous drainage from the cranium to minimize ICP.

A client with a basilar skull fracture has clear fluid leaking from the ears. The nurse should take which action first?

a. Asses the clear fluid for protein

b. Check the clear fluid for glucose

c. Place cotton calls or dry gauze loosely in the ears

d. Use an otoscope to assess the tympanic membrane for rupture

B

CSF contains glucose not protein.