PHT 2162 NEUROLOGICAL TRAUMA CHAPTER 68

PHT 2162 NEUROLOGICAL TRAUMA CHAPTER 68Answer Key Question 1 See full question A client with a spinal cord injury says he has difficulty recognizing the symptoms of urinary tract infection (UTI). Which symptom is an early sign of UTI in a client with a spinal cord injury? Correct response: • Fever and change in urine clarity Explanation: Fever and change in urine clarity as early signs of UTI in a client with a spinal cord injury. Lower back pain is a late sign. A client with a spinal cord injury may not experience a burning sensation or urinary frequency. Question 2 See full question A client is admitted with a cervical spine injury sustained during a diving accident. When planning this client's care, the nurse should assign highest priority to which nursing diagnosis? Correct response: • Ineffective breathing pattern Explanation: Because a cervical spine injury can cause respiratory distress, the nurse should take immediate action to maintain a patent airway and provide adequate oxygenation. Impaired physical mobility, Disturbed sensory perception (tactile), and Dressing or grooming self-care deficit may be appropriate for a client with a spinal cord injury — particularly during the course of recovery — but they don't take precedence over a diagnosis of Ineffective breathing pattern. Question 3 See full question A client who is disoriented and restless after sustaining a concussion during a car accident is admitted to the hospital. Which nursing diagnosis takes the highest priority in this client's care plan? Correct response: • Risk for injury Explanation: Because the client is disoriented and restless, the most important nursing diagnosis is Risk for injury. Although Disturbed sensory perception (visual), Dressing or grooming self-care deficit, and Impaired verbal communication may all be appropriate, they're secondary because they don't immediately affect the client's health or safety. Question 4 See full question When planning care for a client with a head injury, which position should the nurse include in the care plan to enhance client outcomes? Correct response: • 30-degree head elevation Explanation: For clients with increased intracranial pressure (ICP), the head of the bed should be elevated to 30 degrees to promote venous outflow. Trendelenburg's position is contraindicated because it can raise ICP. Flat or