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.

Answer and Explanation

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

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is ["B","D"]

Explanation

A. Slurred speech is often an early sign of increased ICP due to focal brain injury affecting speech areas.
B. Bradycardia is a late sign of increased ICP and is part of Cushing's triad, which includes bradycardia, irregular respirations, and widened pulse pressure
C. Hypotension is not typically associated with increased ICP; in fact, hypertension may occur as the body attempts to maintain cerebral perfusion.
D. Nonreactive dilated pupils are a late sign of increased ICP, indicating potential compression of the third cranial nerve due to brain herniation.
E. Confusion can be an early or late sign of increased ICP, but it is not specific enough to be considered a definitive late sign without other context.

A. Turn the client's head to the side. B. Loosen the clothing around the client's waist. C. Document the time the seizure began. D. Check the client's motor strength.

Correct Answer is A

Explanation

A. Turn the client's head to the side: This action helps prevent aspiration by allowing any oral secretions or vomitus to drain out of the mouth, reducing the risk of airway obstruction and aspiration pneumonia.

B. Loosen the clothing around the client's waist: While it's important to ensure the client's safety during a seizure, addressing airway protection takes precedence over loosening clothing. Loosening clothing can be done after ensuring airway patency.

C. Document the time the seizure began: Documenting the time of onset is important for accurately assessing the duration of the seizure, but it is not the first action to take during an active seizure.

D. Check the client's motor strength: Assessing motor strength is important for evaluating the
client's condition after the seizure has ended, but it is not the first action to take during an active seizure. Ensuring airway protection and preventing injury are the priorities during the seizure.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

Which action should the nurse include in the plan of care for a patient who has cauda equina syndrome related to spinal cord injury?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has an intracranial pressure (ICP) reading of 40 mm Hg. Which of the following findings should the nurse identify as a late sign of ICP? (Select all that apply.)

Correct Answer is ["B","D"]

Explanation

A nurse is in a client's room when the client begins having a tonic-clonic seizure. Which of the following actions should the nurse take first?

Correct Answer is A

Explanation

A nurse is assessing a client who has meningitis and notes when passively flexing the client's neck there is an involuntary flexion of both legs. Which of the following conditions is the client displaying?

An acute care nurse receives shift report for a client who has increased intracranial pressure. The nurse is told that the client demonstrates decorticate posturing. Which of the following findings should the nurse expect to observe when assessing the client?

Which intervention should the nurse include in the plan of care for a patient with new right- sided homonymous hemianopsia after a stroke?

A nurse is assessing a client who has meningitis. Which of the following findings should the nurse expect?

A nurse is caring for a client who has quadriplegia from a spinal cord injury and reports having a severe headache. The nurse obtains a blood pressure reading of 210/108 mm Hg and suspects the client is experiencing autonomic dysreflexia. Which of the following actions should the nurse take first?

A nurse is caring for a client who has had a spinal cord injury at the level of the T2-T3 vertebrae. When planning care, the nurse should anticipate which of the following types of disability?