The nurse is caring for a patient who suffered a spinal cord injury (SCI) who has had halo traction placed for spinal immobilization. What emergency equipment should the nurse have at the bedside? (SELECT ALL THAT APPLY)
Padded tongue blades to prevent injury in the event of seizure
Soft wrist restraints to prevent injury
Ambu bag and oxygen connection for respiratory distress
Wrenches for emergency removal of traction equipment
Oral suction tube (Yankaur) for secretion removal
Correct Answer : C,D,E
A. Padded tongue blades are not appropriate for seizure management and are not necessary in this context.
B. Soft wrist restraints are not required in this scenario unless otherwise indicated.
C. An Ambu bag and oxygen are crucial for respiratory support, especially if the patient has compromised breathing due to spinal cord injury.
D. Wrenches should be readily available to quickly remove halo traction in case of an emergency, such as if the patient's airway needs to be accessed.
E. An oral suction tube (Yankauer) is important for managing oral secretions, which can be challenging for patients with limited mobility.
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Correct Answer is B
Explanation
A. Appetite changes are a possible side effect but are not as critical to report immediately.
B. Severe abdominal pain may indicate pancreatitis or liver issues, both serious side effects of valproic acid that require prompt medical attention.
C. Mild indigestion can be a common, non-serious side effect of valproic acid and does not typically require urgent attention.
D. Weight gain is another common side effect of valproic acid but does not necessitate immediate reporting unless it becomes significant.
Correct Answer is D
Explanation
A. Establishing IV access may be necessary if hypotension persists but is not the initial priority.
B. Bladder distension assessment is essential for managing autonomic dysreflexia in SCI patients; however, symptoms here suggest orthostatic hypotension rather than autonomic dysreflexia.
C. Rescheduling therapy may be considered if dizziness persists, but it does not address the immediate concern.
D. Lowering the head of the bed and obtaining vital signs can help stabilize blood pressure and monitor for orthostatic hypotension, which is common in patients with SCI due to autonomic dysfunction. This intervention helps to prevent syncope.