Which action should the nurse include in the plan of care for a patient who has cauda equina syndrome related to spinal cord injury?
Catheterize the patient every 3 to 4 hours.
Administer medications to reduce bladder spasm.
Assist the patient to ambulate 4 times daily.
Stabilize the neck when repositioning the patient.
The Correct Answer is B
A. Catheterize the patient every 3 to 4 hours: Catheterization may be necessary for urinary retention, which is common in cauda equina syndrome, but it should not be done routinely every 3 to 4 hours. Indwelling catheters increase the risk of urinary tract infections and should be avoided unless necessary.
B. Administer medications to reduce bladder spasm: Bladder spasm is a common complication of cauda equina syndrome and can lead to urinary retention. Medications such as anticholinergics or alpha-adrenergic blockers may be prescribed to reduce bladder spasm and facilitate urine elimination.
C. Assist the patient to ambulate 4 times daily: Ambulation may not be appropriate for a patient with cauda equina syndrome, especially if they have significant motor or sensory deficits. Ambulation should be assessed on an individual basis and may require assistance or adaptive devices.
D. Stabilize the neck when repositioning the patient: Cauda equina syndrome affects the lower spinal cord and does not typically involve the cervical spine. Stabilizing the neck is important in patients with cervical spine injuries but is not directly related to cauda equina syndrome.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Administer an oral analgesic: Administering analgesics may provide relief from pain, but it does not address the underlying cause of the headache and stiff neck. Assessing the client's neurological status is the priority to determine the severity and potential cause of the symptoms.
B. Perform a complete blood count: While laboratory tests may be necessary to further evaluate the client, they are not the first action to take when the client presents with symptoms suggestive of a neurological emergency such as meningitis. Assessing the client's neurological status and ruling out serious conditions take precedence.
C. Evaluate the client's neurological status: Assessing the client's neurological status, including level of consciousness, motor and sensory function, and signs of meningeal irritation (such as neck stiffness), is crucial for identifying potential neurological emergencies such as meningitis and guiding further management.
D. Check the client's temperature: While obtaining vital signs, including temperature, is important in the assessment of a client with suspected meningitis, it is not the first action to take. Assessing the client's neurological status and initiating appropriate interventions based on the findings are the priority.
Correct Answer is C
Explanation
A. Check the client's phenytoin (Dilantin) level: Checking the phenytoin level would not be relevant in this situation as the client's presentation suggests a possible stroke, not related to phenytoin therapy.
B. Get an order to decrease the rate of IV fluids: While managing fluid balance is important, there is insufficient information to warrant decreasing IV fluids at this time. It's essential to assess the client's overall condition and consult with the healthcare provider before making changes to IV fluid administration.
C. Ask the woman to describe how she's feeling: Assessing the client's symptoms and response to treatment is crucial for monitoring her condition and guiding further interventions, especially in
the context of a possible stroke.
D. Offer the client clear liquids to prevent dehydration: While maintaining hydration is
important, offering clear liquids would not address the potential stroke or irregular respirations. Assessment and intervention related to the client's neurological status and respiratory function take precedence.
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