Ch. 43 Care of Patients with Problems of the CNS: Spinal Cord

The nurse is teaching a client about self-management measures to help prevent low back pain. Which teaching should be included? (Select all that apply.) a. "Losing weight can decrease strain on your back." b. "Avoid twisting at your waist." c. "Exercise on a regular basis, including walking." d. "Don't bend at your waist when lifting a heavy object." e. "Eat foods high in calcium and Vitamin D to prevent bone loss."

a, b, c, d, and e

The nurse is developing a teaching plan for a client with a history of low back pain. Which instructions does the nurse plan to include in teaching the client about preventing low back pain and injury? Select all that apply. a. "Do not wear high-heeled shoes." b. "Keep weight within 50% of ideal body weight." c. "Begin a regular exercise program." d. "When lifting something, the back should be straight and the knees bent." e. "Standing for long periods of time will help to prevent low back pain."

a, c, and d

A client with severe muscle spasticity has been prescribed tizanidine (Zanaflex, Sirdalud). The nurse instructs the client about which adverse effect of tizanidine? a. Drowsiness b. Hirsutism c. Hypertension d. Tachycardia

a. Drowsiness

A client returns to the neurosurgical floor after undergoing an anterior cervical diskectomy and fusion (ACDF). What is the nurse's first action? a. Administer pain medication. b. Assess airway and breathing. c. Assist with ambulation. d. Check the client's ability to void.

b. Assess airway and breathing.

A client with a T6 spinal cord injury who is on the rehabilitation unit suddenly develops facial flushing and reports a severe headache. Blood pressure is elevated, and the heart rate is slow. Which action does the nurse take first? a. Check for fecal impaction. b. Help the client sit up. c. Insert a straight catheter. d. Loosen the client's clothing.

b. Help the client sit up.

A nurse is caring for a client who has a hard cervical collar for a complete cervical spinal cord injury. Which assessment finding will the nurse report to the health care provider? a. Purulent drainage from the pin sites on the patient's forehead b. Painful pressure ulcer under the collar c. Inability to move legs or feet d. Oxygen saturation of 95% on room air

b. Painful pressure ulcer under the collar

The nurse is providing instructions to a client with a spinal cord injury about caring for the halo device. The nurse plans to include which instructions? a. "Avoid using a pillow under the head while sleeping." b. "Begin driving 1 week after discharge." c. "Keep straws available for drinking fluids." d."Swimming is recommended to keep active."

c. "Keep straws available for drinking fluids."

A client on the neurosurgical floor who had a lumbar laminectomy is confused, agitated, and complaining of difficulty breathing. The client is normally alert and oriented. The nurse notices a pinpoint rash over the client's chest. What condition is the nurse concerned has occurred? a. Autonomic dysreflexia b. CSF leak c. Fat embolism syndrome d. Paralytic ileus

c. Fat embolism syndrome

The nurse is caring for a client with a spinal cord injury resulting from a diving accident, who has a halo fixator and an indwelling urinary catheter in place. The nurse notes that the blood pressure is elevated and that the client is reporting a severe headache. The nurse anticipates that the primary health care provider will prescribe which medication? a. Dopamine hydrochloride (Inotropin) b. Methylprednisolone (Solu-Medrol) c. Nifedipine (Procardia) d. Ziconotide (Prialt)

c. Nifedipine (Procardia)

Which nursing intervention is best for preventing complications of immobility when caring for a client with spinal cord problems? a. Encouraging nutrition b. Frequent ambulation c. Regular turning and repositioning d. Special pressure-relief devices

c. Regular turning and repositioning

The nurse is caring for a client postoperatively after an anterior cervical diskectomy and fusion. Which assessment finding is of greatest concern to the nurse? a. Neck pain is at a level 7 on a 0-to-10 scale. b. Serosanguineous fluid oozes onto the neck dressing. c. The client is reporting difficulty swallowing secretions. d. The client has numbness and tingling bilaterally down the arms.

c. The client is reporting difficulty swallowing secretions.

The nurse is caring for a client in the emergency department (ED) whose spinal cord was injured at the level of C7 1 hour prior to arrival. Which assessment finding requires the most rapid action? a. After two fluid boluses, the client's systolic blood pressure remains 80 mm Hg. b. Cardiac monitor shows a sinus bradycardia at a rate of 50 beats/min. c. The client's chest moves very little with each respiration. d. The client demonstrates flaccid paralysis below the level of injury.

c. The client's chest moves very little with each respiration.

A client who has just undergone spinal surgery must be moved. How does the nurse plan to move this client? a. Getting the client up in a chair b. Keeping the client in the Trendelenburg position c. Lifting the client in unison with other health care personnel d. Log rolling the client

d. Log rolling the client

In the emergency department (ED), which is the nursing priority in assessing the client with a spinal cord injury? a. Indication of allergies b. Level of consciousness c. Loss of sensation d. Patent airway

d. Patent airway

A client who sustained a recent cervical spinal cord injury reports feeling flushed. His blood pressure is 180/100. What is the nurse's best action at this time? a. Perform a bladder assessment. b. Insert an indwelling urinary catheter. c. Turn on a fan to cool off the patient. d. Place the client in a sitting position.

d. Place the client in a sitting position.

A client is admitted with a spinal cord injury at the seventh cervical vertebra secondary to a gunshot wound. Which nursing intervention is the priority for this client's care? a. Auscultating bowel sounds every 2 hours b. Beginning a bladder retraining program c. Monitoring nutritional status d. Positioning the client to maximize ventilation potential

d. Positioning the client to maximize ventilation potential