The nurse is evaluating the neurological signs of a client in spinal shock following spinal cord injury. Which of the following observations by the nurse indicates that spinal shock persists?
1. Hyperreflexia
2. Positive reflexes
3. Reflex emptying of the bladder
4. Flaccid paralysis
Spinal shock
Description
Spinal shock is also known as neurogenic shock.
A sudden depression of reflex activity in the spinal cord occurs below the level of injury (areflexia).
Spinal shock occurs within the first hour of injury and can last days to months.
The muscles become completely paralyzed and flaccid, and reflexes are absent.
Spinal shock ends when the reflexes are regained.
Assessment
Spinal Shock
Flaccid paralysis
Loss of reflex activity below the level of the injury
Bradycardia
Paralytic ileus
Hypotension
Autonomic Dysreflexia
Sudden onset, severe throbbing headache
Severe hypertension
Flushing above the level of the injury
Pale extremities below the level of the injury
Nasal stuffiness
Nausea
Dilated pupils or blurred vision
Sweating
Piloerection (goose bumps)
Restlessness and a feeling of apprehension
Interventions
Monitor for signs of spinal shock following a spinal cord injury.
Monitor for hypotension and bradycardia.
Monitor for reflex activity.
Assess bowel sounds.
Monitor for bowel and urinary retention.
Provide supportive measures as prescribed,
based on the presence of symptoms.
Monitor for the return of reflexes.
The nurse is assessing the motor function of an unconscious client. The nurse would plan to use which of the following to test the client’s peripheral response to pain?
1. Sternal rub
2. Nail bed pressure
3. Pressure on the orbital rim
4. Squeezing of the sternocleidomastoid muscle
THE UNCONSCIOUS CLIENT
Description
The unconscious client is in a state of depressed cerebral functioning with unresponsiveness to stimulation of sensory and motor function.
Some causes include head trauma, cerebral toxins, shock, hemorrhage, tumor, and infection.
Assessment
Unarousable
Primitive or no response to painful stimuli
Altered respirations
Decreased cranial nerve and reflex activity
A client with Meniere’s disease is experiencing severe vertigo. Which instruction should the nurse give to the client to assist in controlling the vertigo?
1. Increase sodium in the diet.
2. Avoid sudden head movements.
3. Lie still and watch the television.
4. Increase fluid intake to 3000 mL a day.
Meniere’s syndrome
Description
Meniere’s syndrome is also called endolymphatic hydrops; it refers to dilation of the endolymphatic system by overproduction or decreased reabsorption of endolymphatic fluid.
The syndrome is characterized by tinnitus, unilateral sensorineural hearing loss, and vertigo.
Symptoms occur in attacks and last for several days, and the client becomes totally incapacitated during the attacks.
Initial hearing loss is reversible but as the frequency of attacks continues, hearing loss becomes permanent. A priority nursing intervention in the care of a client with Meniere’s syndrome is instituting safety measures.
Causes
Any factor that increases endolymphatic secretion in the labyrinth
Viral and bacterial infections
Allergic reactions
Biochemical disturbances
Vascular disturbance, producing changes in the microcirculation in the labyrinth
Long-term stress may be a contributing factor.
Assessment
Feelings of fullness in the ear
Tinnitus, as a continuous low-pitched roar or humming sound, that is present much of the time but worsens just before and during severe attacks
Hearing loss that is worse during an attack
Vertigo, periods of whirling, that might cause the client to fall to the ground
Vertigo that is so intense that even while lying down, the client holds the bed or ground in an attempt to prevent the whirling
Nausea and vomiting
Nystagmus
Severe headaches
The nurse is caring for a hearing-impaired client. Which of the following approaches will facilitate communication?
1. Speak loudly.
2. Speak frequently.
3. Speak at a normal volume.
4. Speak directly into the impaired ear.
Hearing Impairments
Description:
A hearing impairment is a hearing loss that prevents a person from totally receiving sounds through the ear. If the loss is mild, the person has difficulty hearing faint or distant speech. A person with this degree of hearing impairment may use a hearing aid to amplify sounds. If the hearing loss is severe, the person may not be able to distinguish any sounds.
There are four types of hearing loss:
Conductive: caused by diseases or obstructions in the outer or middle ear that usually affect all frequencies of hearing. A hearing aid generally helps a person with a conductive hearing loss.
Sensorineural: results from damage to the inner ear. This loss can range from mild to profound and often affects certain frequencies more than others. Sounds are often distorted, even with a hearing aid.
Mixed: occurs in both the inner and outer or middle ear.
Central: results from damage to the central nervous system.
People with hearing impairment can communicate using numerous methods of communication, such as:
American Sign Language (ASL): This is the primary language of people who are deaf. It consists of a combination of hand movements and positions to express thoughts and phrases.
Finger spelling: This is a manual form of communication in which the hand and fingers spell out letters of the alphabet to form words.
Lipreading: This is a difficult skill used only by about 10% of people with hearing impairments. Therefore, don’t assume that a deaf person to whom you are speaking can lip read. Even if a person cannot lip read, however, being allowed to see the speaker’s mouth provides helpful visual cues.
Written communication (“Pad and Pencil”): This is a fairly simple way to communicate with a person who is deaf. Remember, however, that sign language is the primary language for most persons who are deaf; English is a second language, so keep your words simple.
Oral communication
The nurse is caring for a client following enucleation. The nurse notes the presence of bright red drainage on the dressing. Which nursing action is appropriate?
1. Notify the physician.
2. Document the finding.
3. Continue to monitor the drainage.
4. Mark the drainage on the dressing and monitor for any increase in bleeding.
Enucleation and exenteration
Description
Enucleation is the removal of the entire eyeball.
Exenteration is the removal of the eyeball and surrounding tissues and bone.
The procedures are performed for the removal of ocular tumors.
After the eye is removed, a ball implant is inserted to provide a firm base for a socket prosthesis and to facilitate the best cosmetic result.
A prosthesis is fitted about 1 month after surgery.
Preoperative interventions
Provide emotional support to the client.
Encourage the client to verbalize feelings related to loss.
Postoperative interventions
Monitor vital signs.
Assess a pressure patch or dressing as prescribed.
Report changes in vital signs or the presence of bright red drainage on the pressure patch or dressing.