Page 2057 - Saunders Comprehensive Review For NCLEX-RN

Level of Cognitive Ability: Analyzing
Client Needs: Physiological Integrity
Integrated Process: Nursing Process—Implementation
Content Area: Adult Health: Neurological
Health Problem: Adult Health: Neurological: Spinal cord injury
Priority Concepts: Caregiving; Intracranial Regulation
Reference: Lewis et al. (2017), p. 1431.

709. Answer: 3

Rationale: Resolution of spinal shock is occurring when there is return of reflexes
(especially flexors to noxious cutaneous stimuli), a state of hyper-reflexia rather than
flaccidity, and reflex emptying of the bladder.
Test-Taking Strategy: Recall that spinal shock is characterized by the loss of
movement of skeletal muscles, loss of bowel or bladder wall function, and depressed
reflex action. Return of any of these indicates that spinal shock is beginning to
resolve. Note that options 1, 2, and 4 are comparable or alike, indicating the
presence of reflexes.
Level of Cognitive Ability: Evaluating
Client Needs: Physiological Integrity
Integrated Process: Nursing Process—Evaluation
Content Area: Adult Health: Neurological
Health Problem: Adult Health: Neurological: Spinal cord injury
Priority Concepts: Evidence; Intracranial Regulation
Reference: Lewis et al. (2017), p. 1420.

710. Answer: 1, 3, 4

Rationale: Nursing actions during a seizure include providing for privacy,
loosening restrictive clothing, removing the pillow and raising padded side rails in
the bed, and placing the client on 1 side with the head flexed forward, if possible, to
allow the tongue to fall forward and facilitate drainage. The limbs are never
restrained because the strong muscle contractions could cause the client harm. If the
client is not in bed when seizure activity begins, the nurse lowers the client to the
floor, if possible; protects the head from injury; and moves furniture that may injure
the client.
Test-Taking Strategy: Focus on the subject, interventions during a seizure. Think
about ethical and legal issues to eliminate option 5. Next, evaluate this question from
the perspective of causing possible harm. No harm can come to the client from any
of the options except for restraining the limbs. Remember to avoid restraints.
Level of Cognitive Ability: Applying
Client Needs: Physiological Integrity
Integrated Process: Nursing Process—Implementation
Content Area: Adult Health: Neurological
Health Problem: Adult Health: Neurological: Seizure disorder/epilepsy
Priority Concepts: Intracranial Regulation; Safety
Reference: Ignatavicius, Workman, Rebar (2018), p. 878.

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