adult health

Question 1

Respiratory paralysis:

Answer 1

Clients with injury to the
cervical spine are at risk for respiratory failure
from diaphragm paralysis. Monitor respiratory
status and prepare for intubation as needed.

Question 2

Spinal immobilization:

Answer 2

Always suspect SCI from
any trauma until it can be ruled out. Immediately immobilize the spine with a cervical collar and only move the client using a logrolling technique.

Question 3

Halo traction:

Answer 3

Monitor for infection at pin sites,
check for pressure injuries under the vest, and
keep a wrench at the bedside for emergency

Question 4

Autonomic dysreflexia:

Answer 4

Monitor for signs of AD,
such as headache, severe HTN, and bradycardia. If AD occurs, immediately raise the HOB and remove noxious stimuli (e.g., catheterize a distended bladder).

Question 5

Postoperative spinal surgery:

Answer 5

Nursing priorities following spinal surgery include maintaining spinal alignment
and monitoring sensory and motor function in the lower extremities.