Ch 43

The nurse is giving home care instructions to a patient who will be discharged with a halo device. What does the nurse instruct the patient to avoid? A. Going out in the cold B. Driving C. Sexual activity D. Bathing in the bathtub

B. Driving

A client has a functional transection of the spinal cord at C7-8, resulting in spinal shock. Which clinical indicators does the nurse expect to identify when assessing the client immediately after the injury? SATA A. Spasticity B. Incontinence C. Flaccid paralysis D. Respiratory failure E. Lack of reflexes below the injury

C. Flaccid paralysis E. Lack of reflexes below the injury

What is a potential adverse outcome of autonomic dysreflexia in a patient with a spinal cord injury? A. Heatstroke B. Paralytic ileus C. Hypertensive stroke D. Aspiration and pneumonia

C. Hypertensive stroke

A patient with a spinal cord injury has paraplegia and paraparesis. The nurse assess the calf area of both legs for swelling, tenderness, redness, or pain. This assessment is specific to the patient's increased risk for which condition? A. Contractures of joints B. Bone fractures C. Pressure ulcers D. Venous thromboembolism

D. Venous thromboembolism

A client with a spinal cord injury has paraplegia. The nurse assesses for which major problem the client may experience early in the recovery period? A. Bladder control B. Nutritional intake C. Quadriceps setting D. Use of aids for ambulation

A. Bladder control

After a client is treated for a spinal cord injury, the health care provider informs the family that the client is a paraplegic. The family asks the nurse what this means. What explanation should the nurse provider? A. Lower extremities are paralyzed B. Upper extremities are paralyzed C. One side of the body is paralyzed D. Both lower and upper extremities are paralyzed

A. Lower extremities are paralyzed

The home health nurse reads in the patient's chart that he has a spinal cord injury and has developed a heterotopic ossification of the right hip. What would the nurse expect to observe while assessing the hip? A. Redness, warmth, and decreased range of motion B. Obvious deformity, with protrusion of the hip joint C. Pronounced muscle atrophy and wasting of the femur D. Poor skin turgor, with fragility and possibile skin tears

A. Redness, warmth, and decreased range of motion

The nurse is helping a client with a spinal cord injury to establish a bladder retraining program. Which strategies may stimulate the client to void? SATA A. Stroking the client's inner thigh B. Pulling on the client's pubic hair C. Initiating intermittent straight catheterization D. Pouring warm water over the client's perineum E. Tapping the bladder to stimulate the detrusor muscle F. Reminding the client to void in a urinal every hour while awake

A. Stroking the client's inner thigh B. Pulling on the client's pubic hair D. Pouring warm water over the client's perineum E. Tapping the bladder to stimulate the detrusor muscle

What should the nurse assess for when a client with a cervical injury reports a severe headache and nasal congestion? A. Suprapubic distention B. Increased spinal reflexes C. Adventitious breath sounds D. Imminent development of shock

A. Suprapubic distention

Which neurologic assessment technique does the nurse use to test a patient for sensory function? A. Touch the skin with a clean paper clip and ask whether it feels sharp or dull B. Ask the patient to elevate both arms off the bed and extend wrists and fingers C. Have the patient close the eyes and move toes up or down, while identifying the positions D. Have the patient sit with the legs dangling; use a reflex hammer to test reflex responses

A. Touch the skin with a clean paper clip and ask whether it feels sharp or dull

A client with a cervical spinal cord injury has been placed in a fixed skeletal traction with a halo fixation device. When caring for this client, the nurse may assign which actions to the LPN/LVN? SATA A. Checking the client's skin for pressure from the device B. Assessing the client's neurologic status for changes C. Observing the halo insertion sites for signs of infection D. Cleaning the halo insertion sites with hydrogen peroxide E. Developing the nursing plan of care for the client F. Administering oral medications as ordered

A. Checking the client's skin for pressure from the device C. Observing the halo insertion sites for signs of infection D. Cleaning the halo insertion sites with hydrogen peroxide F. Administering oral medications as ordered

The nurse is caring for a patient who has been in a long-term care facility for several months following a spinal cord injury. The patient has had problems with urinary retention and subsequent overflow incontinence, and a bladder retraining program was recently initiated. What is an expected outcome of the training program? A. Does not experience a urinary tract infection B. Catheterizes himself independently C. Controls incontinence by decreasing fluid intake D. Takes initiative to call for help when needed

A. Does not experience a urinary tract infection

A nurse finds a victim under the wreckage of a collapsed building. The individual is conscious, supine, breathing satisfactorily, and reporting back pain and an inability to move the legs. Which action should the nurse take first? A. Leave the individual lying on the back with instructions not to move, and seek additional help B. Roll the individual onto the abdomen, place a pad under the head, and cover with any material available C. Gently raise the individual to a sitting position to see whether the pain either diminishes or increases in intensity D. Gently lift the individual onto a flat piece of lumbar and, using any available transportation, rush to the closest medical institution

A. Leave the individual lying on the back with instructions not to move, and seek additional help

A patient has just undergone a spinal fusion and a laminectomy and has returned from the operating room. Which assessments are done in the first 24 hours? SATA A. Take vital signs every 4 hours and assess for fever and hypotension B. Perform a neurologic assessment every 4 hours with attention to movement and sensation C. Monitor intake and output and assess for urinary retention D. Assess for ability and independence in ambulating and moving in bed E. Observe for clear fluid on or around the dressing F. Assess for and immediately report sudden onset of headache

A. Take vital signs every 4 hours and assess for fever and hypotension B. Perform a neurologic assessment every 4 hours with attention to movement and sensation C. Monitor intake and output and assess for urinary retention E. Observe for clear fluid on or around the dressing F. Assess for and immediately report sudden onset of headache

The nurse is caring for a patient who is experiencing spinal shock. What are expected findings that occur with this condition? A. Temporary loss of motor, sensory, reflex, and autonomic functions B. Stridor, garbled speech, or inability to clear airway C. Hypotension and a decreased level of consciousness D. Bradycardia and decreased urinary output

A. Temporary loss of motor, sensory, reflex, and autonomic functions

A nurse in a rehabilitation center teaches clients with quadriplegia to use an adaptive wheelchair. Why is it important that the nurse provide this instruction? A. They usually will never walk B. It prepares them for wearing braces C. It assists them in overcoming orthostatic hypotension D. They have the strength in the upper extremities for self-transfer

A. They usually will never walk

A teenager dove head first into a rock quarry pond and is brought to the emergency department by emergency medical services (EMS). Which questions will the nurse ask the EMS? SATA A. What were the location and position of the patient immediately after the injury? B. Were there problems extricating the patient from the water? C. Have the parents been notified to get permission for treatment? D. What symptoms were reported by bystanders and noted en route? E. What changes occurred at the scene or en route? F. What treatments were given at the scene or en route?

A. What were the location and position of the patient immediately after the injury? B. Were there problems extricating the patient from the water? D. What symptoms were reported by bystanders and noted en route? E. What changes occurred at the scene or en route? F. What treatments were given at the scene or en route?

The nurse is preparing to physically assess a patient's report of paresthesia in the lower extremities. To accomplish this assessment, which assessment technique does the nurse use? A. Use a Doppler to locate the pedal pulse, the dorsalis pedis pulse, or the popliteal pulse B. Ask the patient to identify sharp and dull sensation by using a paperclip and cotton ball C. Use a reflex hammer to test for deep tendon patellar or Achilles reflex D. Ask the patient to walk across the room, and observe gait and equilibrium

B. Ask the patient to identify sharp and dull sensation by using a paperclip and cotton ball

A patient who was involved in a high-speed motor vehicle accident sustained multiple injuries. He is transported to the emergency department by emergency medical services with immobilization devices in place. There is a high probability of cervical spine fracture; the patient has altered mental status and extremities are flaccid. What is the priority assessment for this patient? A. Check the mental status using the Glasgow Coma Scale B. Assess the respiratory pattern and ensure patent airway C. Observe for intraabdominal bleeding and hemorrhage D. Assess for loss of motor function and sensation

B. Assess the respiratory pattern and ensure patent airway

A client is in the intensive care unit after sustaining a T2 spinal cord injury. Which priority interventions should the nurse include in the client's plan of care? SATA A. Minimizing environmental stimuli B. Assessing for respiratory complications C. Monitoring and maintaining blood pressure D. Initiating a bowel and bladder training program E. Discussing long-term treatment plans with the family

B. Assessing for respiratory complications C. Monitoring and maintaining blood pressure

A client with a spinal cord injury (SCI) reports sudden severe throbbing headache that started a short time ago. Assessment of the client reveals increased blood pressure (168/94 mm Hg) and decreased heart rate (48 beats/min), diaphoresis, and flushing of the face and neck. What action should the nurse take first? A. Administer the ordered acetaminophen B. Check the Foley tubing for kinks or obstruction C. Adjust the temperature in the client's room D. Notify the health care provider about the change in status

B. Check the Foley tubing for kinks or obstruction

The nurse is floated from the emergency department to the neurologic floor. Which action should the nurse delegate to the unlicensed assistive personnel (UAP) when providing nursing care for a client with a spinal cord injury? A. Assessing the client's respiratory status every 4 hours B. Checking and recording the client's vital signs every 4 hours C. Monitoring the client's nutritional status, including calorie counts D. Instructing the client how to turn, cough, and breathe deeply every 2 hours

B. Checking and recording the client's vital signs every 4 hours

Which patient behavior is most likely to occur with spinal shock? A. Demonstrates restlessness and is easily agitated B. Displays inability or difficulty moving extremities C. Is disoriented to person, place, and time D. Reports severe pain that radiates down the spine

B. Displays inability or difficulty moving extremities

The nurse is planning care for a 66-year-old patient with spinal cord injury. Based on the nurse's knowledge of the most likely complication and cause of death for this patient, what would the nurse recommend? A. Increase calcium intake and exercise against resistance B. Ensure influenza and pneumococcal vaccinations are current C. Drink adequate liquids and eat a high-fiber diet D. Practice meticulous skin care, including frequent repositioning

B. Ensure influenza and pneumococcal vaccinations are current

Which symptoms indicate that a patient with a spinal cord injury is experiencing autonomic dysreflexia? SATA A. Flaccid paralysis B. Hypertension C. Tachypnea D. Severe headache E. Blurred vision F. Loss of reflexes below the injury

B. Hypertension D. Severe headache E. Blurred vision

The nurse is caring for several patients who have spinal cord injuries. Which task is best to delegate to the unlicensed assistive personnel? A. Encourage use of incentive spirometry; evaluate the patient's ability to use it correctly B. Log-roll the patient; maintain proper body alignment and place a bedpan for toileting C. Check for skin breakdown under the immobilization devices during bathing D. Insert an indwelling catheter and report the amount and color of the urine

B. Log-roll the patient; maintain proper body alignment and place a bedpan for toileting

The nurse is caring for a patient with a recent spinal cord injury (SCI). Which interventions does the nurse use to target and prevent the potential SCI complication of autonomic dysreflexia? SATA A. Frequently perform passive range-of-motion exercises B. Loosen or remove any tight clothing C. Monitor stool output and maintain a bowel program D. Keep the patient immobilized with neck or back braces E. Monitor urinary output and check for bladder distension F. Maintain stable environment temperature

B. Loosen or remove any tight clothing C. Monitor stool output and maintain a bowel program E. Monitor urinary output and check for bladder distension F. Maintain stable environment temperature

Assessment of a patient with a lower spinal cord injury confirms that the patient has paralysis of the bilateral lower extremities. How does the nurse document this finding? A. Paraparesis B. Paraplegia C. Quadriparesis D. Quadriplegia

B. Paraplegia

The nurse is assessing a patient who presented to the emergency department reporting acute onset of numbness and tingling in the right leg. How does the nurse document this subjective finding? A. Paraparesis B. Paresthesia C. Ataxia D. Quadriparesis

B. Paresthesia

A client has paraplegia as a result of a motorcycle accident. What is the reason the nursing care plan should include turning the client every 1 to 2 hours? A. Maintain comfort B. Prevent pressure ulcers C. Prevent flexion contractures of the extremities D. Improve venous circulation in the lower extremities

B. Prevent pressure ulcers

The nurse is assessing a patient with a spinal cord injury that occurred several months ago. The nurse recognizes that the patient is experiencing autonomic dysreflexia. What is the nurse's first priority action? A. Check for bladder distension B. Raise the head of the bed C. Administer an antihypertensive medication D. Notify the primary health care provider

B. Raise the head of the bed

The nurse is preparing a patient with quadriplegia for discharge and has taught the spouse to assist the patient with a "quad cough" to prevent respiratory complications. Which observation indicates that the spouse has understood what has been taught? A. Spouse assists the patient into a wheelchair or chair and coaches him to do deep coughing B. Spouse places her hands below the patient's diaphragm and pushes upward as the patient exhales C. Spouse places her hands on the patient's lateral chest and pushes inward as the patient exhales D. Spouse assists the patient into a high Fowler's position and encourages him to take deep breaths

B. Spouse places her hands below the patient's diaphragm and pushes upward as the patient exhales

The critical care nurse is assessing a client whose baseline Glasgow Coma Scale (GCS) score in the emergency department was a 5. The current GCS is a 3. What is the nurse's best interpretation of this finding? A. The client's condition is improving B. The client's condition is deteriorating C. The client will need intubation and mechanical ventilation D. The client's medication regimen will need adjustments

B. The client's condition is deteriorating

The nurse and the nursing student are working together to bathe and reposition a patient who is in a halo fixator device. Which action by the nursing student causes the supervising nurse to intervene? A. Uses the log-roll technique to clean the patient's back and buttocks B. Turns the patient by grasping the top of the halo device C. Positions the patient with the head and neck in alignment D. Supports the head and neck area during the repositioning

B. Turns the patient by grasping the top of the halo device

The nurse is caring for a patient with a spinal cord injury who is experiencing neurogenic shock. The patient has a dopamine drip, but the systolic blood pressure is 88 mm Hg. There is a new order to infuse 500 mL of dextran-40 over 4 hours. At what rate does the nurse set the infusion pump? A. 75 mL/hr B. 100 mL/hr C. 125 mL/hr D. 150 mL/hr

C. 125 mL/hr

The patient with a spinal cord injury has a heart rate of 42/minute. Which drug does the nurse expect to administer? A. Methylprednisolone B. Dextran C. Atropine D. Dopamine

C. Atropine

A nurse is caring for a client with a spinal cord injury during the immediate post injury period. What is the primary focus of nursing care during this immediate phase? A. Inhibiting urinary tract infections B. Preventing contractures and atrophy C. Avoiding flexion or hyperextension of the spine D. Preparing the client for vocational rehabilitation

C. Avoiding flexion or hyperextension of the spine

An adolescent patient has quadriplegia as a result of a diving accident. The unlicensed assistive personnel reports that the patient started yelling and spitting at her while she was trying to bathe him. He is angry and hostile, stating, "Nobody is going to do anything else to me! I'm going to get out of this place!" What is the priority patient problem? A. Noncompliance with treatment plan B. Self-care deficit for hygiene C. Difficulties with situational coping D. Feelings of hopelessness

C. Difficulties with situational coping

The nurse is preparing a nursing care plan for a client with a spinal cord injury (SCI) for whom problems of decreased mobility and inability to perform activities of daily living (ADLs) have been identified. The client tells the nurse, "I don't know why we're doing all of this. My life's over." Based on this statement, which additional nursing concern take priority? A. Risk for injury B. Decreased nutrition C. Difficulty with coping D. Impairment of body image

C. Difficulty with coping

After having a traumatic spinal cord severance, a young client is having difficulty accepting the paralysis. One day the client has severe leg spasms and says, "My strength is coming back, and I know I will walk again." The nurse's response should be based on what understanding? A. The nerves are regenerating and motor function is returning B. Motor function may be returning now that the edema is subsiding C. Spinal shock has subsided and the client's reflexes are hyperactive D. The client has developed thrombophlebitis and is experiencing pain

C. Spinal shock has subsided and the client's reflexes are hyperactive

A client with quadriplegia is placed on a tilt table daily. Each day the angle of the head of the table gradually is increased. What should the nurse identify as its purpose when the client asks the reason for the tilt table? A. Facilitates turning B. Prevents pressure ulcers C. Promotes hyperextension of the spine D. Limits loss of calcium from the bones

D. Limits loss of calcium from the bones

A client with a spinal cord injury at level C3 to C4 is being cared for by the nurse in the emergency department (ED). What is the priority nursing assessment? A. Determine the level at which the client has intact sensation B. Assess the level at which the client has retained mobility C. Check the blood pressure and pulse for signs of spinal shock D. Monitor respiratory effort and oxygen saturation level

D. Monitor respiratory effort and oxygen saturation level

A nurse should expect a client with a spinal cord injury to have some spasticity of the lower extremities. What should the nurse include in the plan of care for this client to prevent the development of lower extremity contractures? A. Deep massage B. Active exercise C. Use of a tilt board D. Proper positioning

D. Proper positioning

What problem is the nurse primarily attempting to prevent when encouraging a client with a spinal cord injury to increase oral fluid intake? A. Dehydration B. Skin breakdown C. Electrolyte imbalance D. Urinary tract infections

D. Urinary tract infections