CH 60 Spinal Cord and Peripheral Nerve Problems

The nurse teaches a community group about tetanus prevention and immunizations. The nurse should instruct the adults to receive a tetanus and diphtheria toxoid booster, then wait how many years until another is received? Record the answer using a whole number. years

10 The nurse should teach that adults should receive a tetanus and diphtheria toxoid booster once every 10 years.

A patient presents with an open wound. The nurse reviews the patient's history and determines that a tetanus booster is not necessary. This determination was made because the patient was immunized against tetanus within the past how many years? Record the answer as a whole number.years

5 If an open wound occurs and the patient has not been immunized within five years, then the nurse should consult the health care provider. The health care provider can give a tetanus booster to prevent tetanus. If the patient has been immunized within five years, the booster may be unnecessary

The nurse is caring for a patient admitted to the hospital after a motor vehicle accident. The patient is unable to breathe independently and has been intubated and placed on a ventilator. On the basis of these data, which injury does the nurse suspect? C1-3 C4 C5 C6

A An injury to C1-3 is often fatal. The patient retains movement in the neck and above but has a loss of innervation to the diaphragm and an absence of independent respiratory function. A patient with a C4 injury retains sensation and movement in the neck and above. The patient may be able to breathe without a ventilator. A patient who experiences a C5 injury retains full neck movement and partial shoulder, back, and bicep movement. The patient has a gross ability to move the elbow but is unable to roll over or use the hands. The patient also often has a decreased respiratory reserve. A patient with a C6 injury can move the shoulders and upper back; is able to perform abduction and rotation at the shoulder; and has full biceps to elbow flexion and wrist extension, a weak thumb grasp, and decreased respiratory reserve.

A nurse is caring for a patient who has sustained a spinal cord injury. To prevent autonomic dysreflexia, what should the nurse instruct the patient to avoid? Urine retention Emotional stress Smoking cigarettes People with upper respiratory infections

A Autonomic dysreflexia is a medical emergency that occurs when sensory stimulation below the spinal injury triggers a reaction in the intact autonomic system, with resulting reflex arteriolar spasms that increase blood pressure to an extremely high level. A distended bladder is a common trigger of this condition. Profuse sweating below the level of injury and bradycardia are also seen. Although emotional stress, cigarette smoking, and exposure to upper respiratory infections should be avoided by the patient with a spinal cord injury, these factors are not triggers of autonomic dysreflexia.

Which discharge instruction should the nurse provide to a patient with trigeminal neuralgia? "Eat a diet that is high in protein." "Eat low-calorie foods that are easy to chew." "Avoid hygiene activities during periods of analgesia." "Use a hard-bristled toothbrush to clean dental plaque."

A Because chewing may precipitate the pain of trigeminal neuralgia, the patient may not eat properly. Therefore, the nurse teaches the patient to eat food that is high in protein. The nurse should teach the patient to eat food that is easy to chew and also high in calorie content. Hygiene activities should be performed when analgesia is at its peak so that the patient does not have pain. Tooth brushing can precipitate pain. Hence, the patient should be advised to use a small, soft-bristle toothbrush for oral hygiene.

Which intervention should the nurse perform in the acute care of a patient with autonomic dysreflexia? Urinary catheterization Administration of benzodiazepines Suctioning of the patient's upper airway Placement of the patient in the Trendelenburg position

A Because the most common cause of autonomic dysreflexia is bladder irritation, immediate catheterization to relieve bladder distention may be necessary. Benzodiazepines are contraindicated and suctioning is likely unnecessary. The patient should be positioned upright.

A patient with a history of prostate cancer is admitted to the hospital with severe back pain interfering with activity. A computerized tomography (CT) scan shows a metastatic tumor in the spine. Intravenous dexamethasone is prescribed. What is the desired effect of the medication? Decrease tumor-related edema. Lower the systolic blood pressure. Control elevated serum glucose levels. Improve muscular strength in the lower extremities.

A Dexamethasone, a potent corticosteroid, is given intravenously to decrease inflammation and edema. The pain in the spine area decreases when compression of the spinal cord and ischemia to the area is improved. The medication will not affect muscle strength. Corticosteroid therapy tends to increase blood pressure because of sodium retention and elevate serum glucose levels caused by altered carbohydrate metabolism.

The patient with a spinal cord injury (SCI) is admitted to the intensive care unit. What does the nurse know about this injury? Differences in drug metabolism are related to the level and completeness of the injury. Methylprednisolone (MP) needs to be given intravenously within the first few hours of injury. Low-molecular-weight heparin is not used because of the increased risk of bleeding and hemorrhage. Vasopressor agents are contraindicated, because they can reduce the blood flow to vital organs.

A Drug metabolism and pharmacologic properties are altered in SCI and are based upon the level of injury and how completely the spinal cord was injured. The differences in drug metabolism correlate with the level and completeness of injury. In patients with SCI, MP is no longer approved by the Food and Drug Administration (FDA). Unless contraindicated, low-molecular heparin is given to prevent venous thrombolytic embolism (VTE). Vasopressor agents are prescribed in the acute phase of the injury to keep the mean arterial pressure above 90 mm Hg and to improve perfusion to the spinal cord.

The nurse recalls that which surgical therapy for trigeminal neuralgia is a peripheral procedure? Glycerol rhizotomy Gamma knife radiosurgery Microvascular decompression Percutaneous radiofrequency rhizotomy

A Glycerol rhizotomy is a peripheral procedure used for trigeminal neuralgia where glycerol is injected into one or more branches of the trigeminal nerve. The injection of glycerol causes a chemical ablation resulting in loss of pain sensations. Gamma knife radiosurgery is an intracranial technique that uses high doses of radiation focused on the trigeminal nerve root using stereotactic localization. Microvascular decompression is an intracranial procedure in which the artery pressing on the nerve root is lifted up. Percutaneous radio frequency rhizotomy is an intracranial procedure that involves the destruction of sensory fibers by low-voltage current.

A patient with spinal cord injury has been placed on mechanical ventilation due to failure of the diaphragm. Which possible level of spinal cord injury should the nurse suspect in this case C1-C3 C5-T6 T1-L2 Above T5

A Injury at the C1-C3 spinal level causes damage to the phrenic nerve origin. Therefore, paralysis of the diaphragm takes place, causing respiratory failure. Injuries below C3 do not cause any damage to the phrenic nerve, and the diaphragm is able to contract well. Injury between C5 and T6 causes decreased respiratory reserve. Injuries between T1 and L2 may cause bladder retention. Injuries above T5 may manifest as paralytic ileus.

The nurse is providing care to a patient who is paralyzed from the waist down. Which spinal vertebra injury would have caused this manifestation? Lumbar vertebra 1 Cervical vertebra 4 Cervical vertebra 6 Thoracic vertebra 6

A Injury to lumbar vertebra 1 results in paralysis below the waist. Injury to cervical vertebra 4 results in complete paralysis below the neck. Injury to cervical vertebra 6 results in partial paralysis of the hands and arms and of the lower body. Injury to thoracic vertebra 6 results in paralysis below the chest.

Which manifestations in a patient with a T4 spinal cord injury should alert the nurse to the possibility of autonomic dysreflexia? Headache and rising blood pressure Irregular respirations and shortness of breath Decreased level of consciousness or hallucinations Abdominal distention and absence of bowel sounds

A Manifestations of autonomic dysreflexia are hypertension (up to 300 mm Hg systolic), a throbbing headache, bradycardia, and diaphoresis. Respiratory manifestations, decreased level of consciousness, and gastrointestinal manifestations are not characteristic manifestations.

Which clinical manifestation would the nurse interpret as a manifestation of neurogenic shock in a patient with acute spinal cord injury? Bradycardia Hypertension Neurogenic spasticity Bounding pedal pulses

A Neurogenic shock is caused by the loss of vasomotor tone caused by injury, and is characterized by bradycardia and hypotension. Loss of sympathetic innervations causes peripheral vasodilation, venous pooling, and a decreased cardiac output. Hypertension, neurogenic spasticity, and bounding pedal pulses are not seen in neurogenic shock.

Which is a priority nonoperative treatment following a spinal cord injury? Stabilization Spinal fusion Cervical traction Pain management

A Stabilization eliminates any damaging motion at the injury site to avoid worsening the patient's condition. Pain management is important, but it is a lower priority than stabilization. Spinal fusion is a surgical procedure. Cervical traction is a closed reduction with skeletal traction and is used for early realignment (reduction) of the injury; the patient should be stabilized before a care plan is implemented.

The nurse is providing care to a patient with trismus. Which associated condition does the nurse suspect? Tetanus Botulism Neurosyphilis Guillain-Barré syndrome

A Tetanus is an infection of the nervous system that affects the spinal and cranial nerves. It results from a potent neurotoxin released by the anaerobic bacillus Clostridium tetani. Its initial manifestations include stiffness in the jaw (trismus) and signs of infection. Botulism is caused by gastrointestinal absorption of the neurotoxin produced by Clostridium botulinum. Its neurologic manifestations include descending paralysis with muscle incoordination and weakness, difficulty swallowing, seizures, and respiratory muscle weakness. Manifestations of neurosyphilis include pain in the legs, ataxia, loss of deep tendon reflexes, and zones of hyperesthesia. Guillain-Barré syndrome is characterized by ascending, symmetric paralysis that usually affects the cranial nerves and the peripheral nervous system.

A patient presents with initial manifestations of tetanus. The nurse expects what assessment finding? Stiffness in the jaw Rigidity of the abdomen Continuous tonic seizures Extreme arching of the back

A The initial manifestations of tetanus include trismus or stiffness in the jaw. As the disease progresses, there is rigidity of the abdomen. In severe cases, continuous tonic seizures may occur, leading to opisthotonus or extreme arching of the back and retraction of the head.

The nurse is presenting information to a group of nursing students about the incidence of trigeminal neuralgia. What is appropriate for the nurse to include? It usually affects only one side of the body. It occurs more often in men than in women. It is a rare cause of nerve pain among Americans. It is most common in 20- to 30-year-old individuals.

A Trigeminal neuralgia is usually unilateral. It affects only one side of the body. It occurs almost twice as often in women as in men. It is the most commonly diagnosed neuralgia or nerve pain among Americans. In most cases it is diagnosed in people aged 40 and older.

While assessing a patient, the health care provider observes that the patient has trismus and suspects the patient has a tetanus infection. How would the nurse describe trismus and its relation to tetanus infection? Trismus is stiffness of the jaw and is one of the first manifestations of tetanus. Trismus refers to spasms of the laryngeal and respiratory muscles and is one of the last stages of tetanus. Trismus causes extreme arching of the back and retraction of the head and is unrelated to tetanus. Trismus is the rigidity of neck muscles, back, abdomen, and extremities and is one of the first manifestations of tetanus.

A Trismus or lockjaw is stiffness of the jaw due to spasms of the surrounding muscles. It is one of the initial and characteristic features of tetanus. Other manifestations of tetanus include spasms of laryngeal and respiratory muscles, which could cause anoxia, and extreme arching of the back and retraction of the head, also called opisthotonos, which are due to spasms of the trunk (back mainly) musculature. As the disease progresses, there is extreme rigidity of neck muscles, back, abdomen, and extremities.

The nurse is caring for a patient with trigeminal neuralgia. What conservative therapies are appropriate to be included on the patient's plan for treatment? Select all that apply. Acupuncture Vitamin therapy Glycerol rhizotomy Tricyclic antidepressant Microvascular decompression

A, B The collaborative care for trigeminal neuralgia includes drug therapy, conservative therapy, and surgical therapy. Acupuncture and vitamin therapy are conservative therapy modalities used to treat trigeminal neuralgia. Glycerol rhizotomy is a peripheral surgical therapy for trigeminal neuralgia. Tricyclic antidepressants are part of drug therapy for trigeminal neuralgia. Microvascular decompression is an intracranial surgery used to treat trigeminal neuralgia.

A nurse advises a patient with Bell's palsy to use a facial sling. What benefits of the facial sling should the nurse mention that would encourage the patient to use it? Select all that apply. It facilitates eating. It supports facial muscles. It improves mouth alignment. It improves cosmetic appearance. It immobilizes the face, thereby preventing pain.

A, B, C A facial sling may be helpful to support affected muscles, improve lip alignment, and facilitate eating. A facial sling does not improve cosmetic appearance. The sling allows movements of the face.

What instructions should the nurse give to the patient and caregivers to prevent skin breakdown in the patient with spinal cord injury who can sit in the wheelchair? Select all that apply. Use special mattresses to reduce pressure. Use wheelchair cushions to reduce pressure. Use pillows to protect bony prominences when in bed. If in a wheelchair, lift oneself up and shift weight every two to four hours. If in bed, change positions using a regular turning schedule of six hours.

A, B, C For preventing skin breakdown in the patient with spinal cord injury, the nurse should teach the patient and caregivers to use special mattresses and wheelchair cushions to reduce pressure. Pillows should be used to protect bony prominences when in bed. If in a wheelchair, the patient should be told to lift him- or herself up and shift weight every 15 to 30 minutes to promote circulation. If in bed, position should be changed every two hours.

The nurse is caring for a patient with paraplegia who is at a risk of developing deep vein thrombosis (DVT). What interventions are expected to be done for this patient? Select all that apply. Assess thighs and calves for signs of DVT. Administer prophylactic low-dose low-molecular-weight heparin. Obtain venous Doppler reports before applying compression stockings. Perform passive movements with the patient once deep vein thrombosis is established. Ensure that the patient wears compression stockings continuously throughout the day.

A, B, C Nursing interventions in paraplegics should be aimed at preventing DVT. Assessment of the thighs and calves should be done every shift for signs of DVT. Venous duplex studies may be performed before applying compression devices. Sequential compression devices or compression gradient stockings can be used to prevent thromboemboli and to promote venous return. Remove the stockings every eight hours for skin care. Low-molecular-weight heparin should be administered as a prophylactic measure to prevent thromboembolism. Once deep vein thrombosis is established, it is not advisable to move the limbs, because this may dislodge the thrombus, and pulmonary embolism, which is a life-threatening complication of DVT, may occur.

A patient has been admitted to the hospital with a T3-level complete spinal cord injury. The nurse has to plan the home-based rehabilitation for this patient. When creating the care plan, the nurse considers the activities that the patient is able to do independently. What activities should the nurse consider to make maximum use of patient's abilities? Select all that apply ndependent self-care is possible. Independent wheelchair mobility is possible. Patient may be able to drive with hand controls. Patient will be able to climb stairs independently. Patient will be able to have effective coughing ability.

A, B, C The patient with a T3-level spinal cord injury will have full innervation of the upper extremities, back, essential intrinsic muscles of the hands, full strength and dexterity of grasp, decreased trunk stability, and decreased respiratory reserve. Therefore, the patient may have the following potentials: full independence in self-care and in a wheelchair, ability to drive a car with hand controls, independent standing in a standing frame. Abdominal muscles are affected, so the ability to cough is lost. The patient may also not be able to climb stars due to the injury.

A patient has been admitted to the hospital with a T3-level complete spinal cord injury. The nurse has to plan the home-based rehabilitation for this patient. When creating the care plan, the nurse considers the activities that the patient is able to do independently. What activities should the nurse consider to make maximum use of patient's abilities? Select all that apply. ndependent self-care is possible. Independent wheelchair mobility is possible. Patient may be able to drive with hand controls. Patient will be able to climb stairs independently. Patient will be able to have effective coughing ability.

A, B, C The patient with a T3-level spinal cord injury will have full innervation of the upper extremities, back, essential intrinsic muscles of the hands, full strength and dexterity of grasp, decreased trunk stability, and decreased respiratory reserve. Therefore, the patient may have the following potentials: full independence in self-care and in a wheelchair, ability to drive a car with hand controls, independent standing in a standing frame. Abdominal muscles are affected, so the ability to cough is lost. The patient may also not be able to climb stars due to the injury.

A patient with spinal cord injury has poor nutritional intake. What measures should the nurse take to improve the patient's nutrition? Select all that apply. Provide adequate time to eat. Encourage intake of dietary fiber. Keep a calorie count of the food taken. Provide a pleasant eating environment. Provide a low-protein and low-calorie diet. Feed the patient only hospital-cooked food

A, B, C, D General measures such as providing a pleasant eating environment, allowing adequate time to eat (including any self-feeding the patient can achieve), encouraging the family to bring in special foods to avoid the patient becoming bored with institutional food, and planning social rewards for eating may be useful to improve nutrition of the patient. Keep a calorie count, and record the patient's daily weight to evaluate progress. If feasible, the patient should participate in recording caloric intake. Dietary supplements may be necessary to meet nutritional needs. Increased dietary fiber should be included to promote bowel function. Because there is severe catabolism taking place, a high-protein, high-calorie diet is necessary for energy and tissue repair.

An older adult person has fallen from a step stool and has a lower sacral fracture. The investigation reports also show that there is injury to the conus medullaris. What are the symptoms that the nurse should expect while assessing the patient? Select all that apply. Bowel incontinence Urinary incontinence Difficulty in breathing Hypotonicity of the lower limbs Hypotonicity of the upper limbs

A, B, D Conus medullaris, or cauda equina syndrome, results from damage to the conus (lowest portion of the spinal cord) and cauda equina (lumbar and sacral nerve roots). It is characterized by flaccid paralysis of the lower limbs and areflexic (flaccid) bladder and bowel. There may be decreased anal tone and consequent fecal incontinence. Upper limbs are not affected by injury to the conus. Breathing is not affected, because the injury is to the conus medullaris, which does not control muscles of breathing.

A patient with a cervical spinal cord injury has just been hospitalized. Which nursing interventions for maintaining nutritional balance, if prescribed, are appropriate for this patient? Select all that apply. Insert a nasogastric tube. Evaluate swallowing before starting oral feeding. Prescribe a low-protein and low-carbohydrate diet. If oral feeding is not possible, enteral nutrition must be provided. Gradually introduce oral food and fluids, irrespective of bowel sounds.

A, B, D During the first 48 to 72 hours after the injury, the gastrointestinal (GI) tract may stop functioning (paralytic ileus), and hence a nasogastric tube must be inserted. In patients with high cervical cord injuries, evaluate swallowing before starting oral feedings. If the patient is unable to resume eating, enteral nutrition may be used to provide nutritional support. Once bowel sounds are present or flatus is passed, gradually introduce oral food and fluids. Because of severe catabolism, a high-protein, high-calorie diet is necessary for energy and tissue repair.

A nurse is explaining to a patient with Bell's palsy the preventive measures for complications related to the eye. What instructions should the nurse give the patient? Select all that apply. Wear dark glasses. Tape eyelids at night. Check vision regularly. Instill artificial tears frequently. Keep the room at a moderate temperature.

A, B, D One common complication of Bell's palsy is corneal abrasions and infections due to corneal anesthesia. The patient should wear dark glasses for protective and cosmetic reasons. Taping the lids closed at night may be necessary to provide protection. Artificial tears (methylcellulose) should be instilled frequently during the day to prevent drying of the cornea. The sense of vision is not compromised in facial palsy. Keeping the room at a moderate temperature does not help in preventing eye complications; it may help in preventing triggers of trigeminal neuralgia.

The nurse is giving home instructions to a patient recently diagnosed with Bell's palsy. Which comments by the nurse are most appropriate? Select all that apply. "It is important to maintain good nutrition." "Full recovery generally occurs in 3 to 6 months." "Cold packs need to be applied four times a day for 20 minutes each time." "Dark glasses will help protect your eyes and help to cover up the paralysis." "Chew your food on the same side as the paralysis to prevent the facial muscle from weakening."

A, B, D Thorough oral hygiene must be carried out after each meal to prevent development of parotitis, caries, and periodontal disease. Eating nutritionally is important, and dark glasses help to protect the eyes from light and also have a cosmetic effect. Patients with Bell's palsy generally can expect a complete recovery after six months. Hot wet packs are applied to reduce the discomfort. To prevent trapping of food, teach patients to chew food on the unaffected side.

A patient has been admitted to the hospital with Guillain-Barré syndrome with severe autonomic dysfunction. Which of the dysfunctions should the nurse anticipate and monitor for? Select all that apply. Dysrhythmias Bradycardia Tabes dorsalis Charcot's joints Orthostatic hypotension

A, B, E In Guillain-Barré syndrome, autonomic dysfunction is common and usually takes the form of bradycardia and dysrhythmias. Orthostatic hypotension secondary to muscle atony may occur in severe cases. Tabes dorsalis and Charcot's joints do not occur in Guillain-Barré syndrome; these symptoms are characteristics of neurosyphilis. Tabes dorsalis, or progressive locomotor ataxia, is characterized by vague, sharp pains in the legs. Charcot's joints, which are characterized by enlargement, bone destruction, and hypermobility, also occur as a result of joint effusion and edema.

A quadriplegic patient has been hospitalized for one month, and is therefore at a risk of developing pressure sores. What are the steps that the nurse should take to prevent the development of pressure ulcers? Select all that apply. Check the nutritional status of the patient. Check the patency of the urinary catheter. Change the position of the patient every six hours. Avoid lifting the patient when changing the position. Check bony prominences for signs of pressure sores.

A, B, E Prevention of pressure ulcers and other types of injury to insensitive skin is essential for every patient with a spinal cord injury (SCI). Moisture from incontinence or any urine leakage can contribute to pressure ulcer development by macerating the skin and increasing friction injuries. Assess nutritional status regularly. A comprehensive visual and tactile examination of the skin should be done at least once daily, with special attention given to areas over bony prominences. The areas most vulnerable to breakdown include the ischia, trochanters, heels, and sacrum. Both body weight loss and weight gain can contribute to skin breakdown. When a patient is moved, it must be done in a way to prevent friction and shearing, because these forces will cause skin injury as readily as pressure. The patient must be lifted, not dragged, while repositioning, which also means more than one person may be needed to move the patient. Pulling or dragging the patient will cause skin damage due to friction. Careful positioning and repositioning should be done every two hours.

Which interventions should be included in the teaching plan for the patient with paraplegia who is discharged from a rehabilitation facility? Select all that apply. Use pressure-relief devices while sitting. Change position at least every two hours. Apply massage to areas with sustained redness. Follow a diet high in vitamins and low in protein. Inspect all skin areas on a daily basis using a mirror as necessary.

A, B, E Prevention of skin breakdown is the goal for patients with paraplegia (paralysis of the lower extremities). The patient should inspect the skin, especially pressure areas and bony prominences, at least every 24 hours. Minimally, patients need to change position every two hours to prevent pressure sore development. Because patients sit much of the time, pressure relief devices are needed, especially on wheelchairs. Skin that remains reddened after 30 minutes is showing signs of pressure damage. Massaging the areas will add to the injury. A diet with adequate vitamins and adequate protein is needed to maintain skin integrity.

A nurse is monitoring a patient with spinal cord injury. The nurse reviews the arterial blood gas (ABG) reports and notifies the health care provider that the patient may need mechanical ventilation. Which blood gas abnormality would have led the nurse to this opinion? Select all that apply. pH = 7.27 PaO 2 = 80 mm Hg PaCO 2= 55 mm Hg PaHCO 3 = 26 mm Hg

A, C A pH of 7.27 is indicative of acidosis and a PaCO 2 of more than 45 is indicative of respiratory acidosis. This is due to failure of the ventilatory pump to adequately wash out oxygen. Therefore, ventilator support is a must in this case. A PaO 2 of 80 can be managed well without ventilator support and a PaHCO 3 level of 26 is within normal limits.

The nurse is caring for a patient diagnosed with tetanus. The patient has been given tetanus immune globulin (TIG). What should be the focus of collaborative care? Select all that apply. Control of spasms with diazepam Administration of polyvalent antitoxin Tracheostomy for mechanical ventilation Teaching correct processing of canned foods Administration of facial sling to support affected muscles

A, C Control of the spasms of tetanus is essential because the laryngeal and respiratory system spasms cause apnea and anoxia. A tracheostomy is performed early so mechanical ventilation may be done to maintain ventilation. A facial sling may be administered for Bell's palsy. Use of polyvalent antitoxin and teaching the correct canning process is done for botulism.

The nurse is providing teaching to a group of nursing students about the actions of the primary medications used to treat trigeminal neuralgia. What is appropriate for the nurse to include in the education? Select all that apply. Lamotrigine blocks the nerve firing. Amitriptyline stabilizes the neuronal membrane. Nortriptyline can be used to treat constant burning. Baclofen is a first-line drug for treating the condition. Opioids are highly effective in controlling the nerve pain. Analgesics help to control the pain associated with this condition.

A, C Lamotrigine is an antiseizure drug that stabilizes the neuronal membrane and blocks the nerve firing. Nortriptyline is an antidepressant drug and is a second-line choice that can be used to treat constant burning associated with trigeminal neuralgia. Amitriptyline is also a tricyclic antidepressant that treats constant burning or aching pain. Baclofen is not a first-line drug for treating the condition. It may be given along with a first-line antiseizure drug if a single drug is not effective. Opioids and analgesics are usually not effective in controlling the nerve pain of trigeminal neuralgia.

A computed tomography (CT) scan has to be completed for a patient with spinal cord injury. The nurse has to explain the uses of this procedure to the caregivers in order to obtain their consent. What should the nurse tell the caregivers? Select all that apply. It helps to find the exact location of injury. It helps to diagnose deep vein thrombosis (DVT). It helps to assess changes in the neurologic tissue. It helps to find the degree of spinal canal compromise. It helps to find the presence of any damage to the spinal or vertebral arteries.

A, D For a patient with spinal cord injury, CT scan is the preferred imaging study to diagnose the location and degree of injury and degree of spinal canal compromise. Magnetic resonance imaging is used to assess for soft tissue and neurologic changes and for unexplained neurologic deficits or worsening of neurologic status. Patients with cervical injuries who demonstrate altered mental status may also need a CT angiogram to rule out vertebral artery damage. Duplex Doppler ultrasound, impedance plethysmography, venous occlusion plethysmography, venography, and the clinical examination are recommended for use as diagnostic tests for DVT.

A nurse has to explain to a patient having Bell's palsy the reason why oral hygiene and nutrition are affected in this condition. What points should the nurse emphasize while explaining? Select all that apply. The taste sensation is impaired. The sensation inside the mouth is affected. In Bell's palsy, muscles of mastication are paralyzed. There is accumulation of food on one side of the mouth. There is pain around the jaw, which prevents the proper chewing of food.

A, D, E Bell's palsy is a lower motor neuron facial paralysis of unknown etiology. Malnutrition in Bell's palsy may occur due to inability to chew food and loss of taste sensation because of pain around the jaw. Oral hygiene is affected due to accumulation of food in one side of the mouth. Facial nerves do not supply muscles of mastication; sensation inside the mouth is not affected, because it is carried by the trigeminal nerve

A person who has survived a motor vehicle accident has been diagnosed as having a thoracic level spinal cord injury. A week into hospitalization, the patient is put on mechanical ventilation. The nurse has to explain to the caregivers the reason for mechanical ventilation. What could be the reason for the need for mechanical ventilation in this patient? Select all that apply. There is fluid overload in the lungs. There is severe constriction of airways. The nerve that controls breathing is damaged. The muscle responsible for breathing is paralyzed. There is accumulation of secretions in the lungs, which has caused collapse of the lungs.

A, D, E Cervical and thoracic injuries cause paralysis of abdominal muscles and often the intercostal muscles. Therefore, the patient cannot cough effectively enough to remove secretions, leading to atelectasis and pneumonia. Pulmonary edema may also occur in response to fluid overload. The spinal cord injury is at the thoracic level, so the phrenic nerve and diaphragm are spared. Constriction of larger airways also occurs at a higher spinal cord injury level.

A patient with a T3-level spinal cord injury has been discharged from the hospital with an indwelling catheter for neurogenic bladder. The nurse is teaching the patient regarding the care for indwelling catheters. What instructions should the nurse give regarding home care for indwelling catheters? Select all that apply. Cleanse the catheter regularly. Always keep the urine bag above the waist. Limit water intake to less than a liter a day. Check for the presence of any folds or kinks in the catheter tube. Check for signs of urinary tract infection (fever, change in odor or color of urine).

A, D, E Indwelling catheters should be cleaned regularly, and the method of cleaning should be taught properly by the nurse to the patient to avoid any infections. The patency of the catheter tube should always be checked to prevent any accumulation of urine in the bladder. Long-term use of an indwelling catheter may be associated with urinary tract infection. Signs and symptoms of these conditions should be explained to the patient. The urine bag should always be placed below the level of the bladder to ensure proper drainage. Patients with indwelling catheters need to have an adequate fluid intake (at least 3 to 4 L/day).

A patient with paraplegia has sudden violent movements of the lower limbs. What should the nurse tell the patient and the caregivers about these violent spasms? Select all that apply. These spasms can occur as a result of a variety of stimuli. This occurs due to hyperexcitability of the upper motor neuron. These spasms indicate improvement in the condition of the patient. Such reflexes could be positively used for bowel and bladder retraining. This occurs due to a break in the link between the upper and lower motor neuron interaction.

A, D, E Once the period of spinal shock is resolved, due to lack of control from the higher brain centers, reflexes are often hyperactive and produce exaggerated responses. The upper motor neuron does not have an inhibitory control over the lower motor neuron. Spasms ranging from mild twitches to convulsive movements below the level of injury may also occur. These may occur due to a variety of stimuli. These reflexes are useful in sexual, bowel, and bladder retraining. These spasms do not indicate an improvement in the condition of the patient.

A nurse is preparing a nursing care plan for a patient with trigeminal neuralgia. What information should the nurse elicit during the patient's health history to aid in planning? Select all that apply. Food habits Bowel habits Bladder habits Self-medication to decrease pain Frequency of attacks and triggers

A, D, E Patients with trigeminal neuralgia are primarily treated on an outpatient basis. Patients with trigeminal neuralgia may have difficulty in chewing; therefore it is important to ask about food habits when planning care. Relevant history for the assessment of the attacks includes the triggering factors, characteristics, frequency, and pain management techniques; these help the nurse to plan for patient care. Trigeminal neuralgia does not affect bladder and bowel function; therefore related history is not needed.

A patient has undergone a percutaneous radiofrequency rhizotomy procedure for trigeminal neuralgia and has facial numbness and trigeminal motor weakness on the affected side. What instructions should the nurse give this patient? Select all that apply. Avoid eating hot food or beverages. Regularly shave using a razor blade. Avoid moving the jaw as much as possible. Protect the face from extreme temperatures. Check oral cavity after eating food for any residual food particles.

A, D, E Percutaneous radiofrequency rhizotomy can often result in facial numbness, corneal anesthesia, and trigeminal motor weakness. The nurse should teach the patient to avoid eating hot foods to prevent burns in the mouth and to protect the face from extreme temperatures. Decreased ability to chew and decreased sensation in the mouth may cause deposition of food particles in the mouth, and so the patient should check the oral cavity after eating food. The patient should be encouraged to use electric razors rather than a razor blade for preventing cuts in the face due to the blades. The patient should be encouraged to do jaw movements as much as possible to overcome motor weakness.

The arterial blood gas (ABG) report of a patient with a spinal cord injury reveals that the patient is in respiratory distress. Which nursing interventions, if prescribed, are appropriate for this patient? Select all that apply. dminister oxygen. Administer steroids. Administer antibiotic drugs. Perform tracheal suctioning. Use assisted coughing techniques.

A, D, E To maintain adequate ventilation, the nurse should administer oxygen until ABGs stabilize. Assisted (augmented) coughing simulates the action of the ineffective abdominal muscles during the expiratory phase of a cough, therefore facilitating the removal of secretions. Tracheal suctioning is performed if crackles or rhonchi are present, as indicated by mucus stuck to the airways. Presence of an infection cannot be revealed by an ABG report; therefore it is not appropriate to administer antibiotics. ABG does not reveal any presence of inflammatory process; therefore it is inappropriate to administer steroids to this patient.

A patient with paraplegia has been hospitalized for a week and is not eating anything. What could be the possible causes of patient's anorexia? Select all that apply. Depression Abnormal taste sensation Difficulty in swallowing food Hurried feeding by the nurse Boredom due to institutional food Continuous bed rest and weakness

A, D, E, F Some patients experience anorexia, which can be due to depression, boredom with institutional food, discomfort at being fed (often by a hurried nurse), or continuous bed rest and weakness. Some patients have a normally small appetite. A paraplegic patient has a thoracic or lumbar cord injury; therefore, dysphagia is not a common problem affecting eating in such patients. Taste sensations are usually intact in such patients, and may not be the cause of anorexia.

What type of blunt trauma can lead to a spinal cord injury? Stab wound Diving accident Gunshot wound Torn spinal cord

B A diving accident is a blunt trauma caused by a physical injury that can lead to spinal cord injury. Stab wound, gunshot wounds, and a torn spinal cord are instances of penetrating traumas that can injure the spinal cord.

A nurse is planning a bowel program for a patient with a T7 level spinal cord injury. What is the mostsuitable position for bowel evacuation for this patient? Prone position Sitting position Supine position Standing position

B A patient with T7 level spinal injury will be able to sit; therefore it is best to position the patient upright for proper evacuation, because this position would ensure complete evacuation. The supine position does not facilitate evacuation of the bowels. If the patient is not able to sit upright, it could be done in the side-lying position. The prone position and standing are awkward for bowel evacuation.

While assessing a patient's level of spinal injury, the nurse observes that the patient has sensation and movement in the neck and the region above, and can breathe without a ventilator. What is the potential for rehabilitation that the nurse can expect? Ability to feed self with setup Ability to drive an electric wheelchair Attendant care required for 10 hours in a day Independent computer use with adaptive equipment

B A patient with sensation and movement in the neck and the region above the neck can drive an electric wheelchair by using chin control of a mouth stick. Self-feeding is not possible for the patient because the ability of movement is limited to the neck. The patient requires complete assistance with daily living activities; therefore attendant care is required 24 hours a day. Due to paralysis in the arms and hands, the patient can access the computer only with the help of a mouth stick and head wand. Hence independent use of a computer is not possible.

The nurse is caring for a patient admitted with a spinal cord injury following a motor vehicle accident. The patient exhibits a complete loss of motor, sensory, and reflex activity below the injury level. The nurse recognizes this condition as which of the following? Central cord syndrome Spinal shock syndrome Anterior cord syndrome Brown-Séquard syndrome

B About 50 percent of people with acute spinal cord injury experience a temporary loss of reflexes, sensation, and motor activity that is known as spinal shock. Central cord syndrome is manifested by motor and sensory loss that is greater in the upper extremities than in the lower extremities. Anterior cord syndrome results in motor and sensory loss but not reflexes. Brown-Séquard syndrome is characterized by ipsilateral loss of motor function and contralateral loss of sensory function.

The nurse expects a prescription for what treatment to help control a patient's spasms that are caused by tetanus? Opioids Barbiturates Metronidazole Tetanus immune globulin

B Barbiturates cause muscle relaxation and help control the spasms caused by tetanus. Opioids such as morphine or fentanyl are analgesics that help in pain management. Metronidazole is given to inhibit further growth of the bacteria Clostridium tetani. A large dose of tetanus immune globulin is given to a patient with clinical manifestations of tetanus to neutralize the circulating toxins.

Which instruction should be given to a patient who is diagnosed with Bell's palsy? Sit upright for meals and follow a thickened liquid high protein diet. Prevent corneal drying by instillation of ointment at night with an eye shield. Continue prescribed corticosteroid eye drops until the eye can close properly. Complete the full course of prescribed antibiotics even if eye drainage is nonpurulent.

B Because the patient cannot shut the eye, the cornea may become dry, increasing the risk for injury. Using eye ointment with an eye shield at night will protect the cornea. Systemic corticosteroids are prescribed orally to stop the inflammation and are effective if begun within two weeks of the onset of symptoms. The patient is able to swallow, should chew on the unaffected side, and may have some difficulty with drooling. Antibiotics usually are not prescribed because there is no bacterial infection.

The nurse is preparing educational materials about the differences between Bell's palsy and trigeminal neuralgia. What information should the nurse include about Bell's palsy? It is more common than trigeminal neuralgia. It affects the seventh cranial nerve, whereas trigeminal neuralgia affects the fifth. It causes severe pain, whereas trigeminal neuralgia causes drooping of the mouth. It can affect any age group, whereas trigeminal neuralgia is mostly seen in children.

B Bell's palsy affects the facial nerve, which is the seventh cranial nerve. Trigeminal neuralgia affects the trigeminal nerve, which is the fifth cranial nerve. Bell's palsy occurs in nearly 40,000 Americans each year, whereas, trigeminal neuralgia affects approximately 150,000 Americans every year. Trigeminal neuralgia causes severe pain along the distribution of the trigeminal nerve, whereas, Bell's palsy causes drooping of the mouth due to paralysis of the motor branches of the facial nerve. Bell's palsy can affect any age group, but trigeminal neuralgia is mostly seen in middle aged people.

A patient with facial paralysis comes to the walk-in clinic and is diagnosed with Bell's palsy. What does the nurse understanding about this disorder? Has a poor prognosis Can affect any age group Can occur on both sides of the face. Affects more than 100,000 people every year

B Bell's palsy is a type of peripheral facial paralysis that can affect any age group, although it commonly is seen in the 20- to 60-year-old range. The cause is not well known; it may be theorized that Bell's palsy can be related to activation of herpes simplex virus (HSV-1). It has a good prognosis. It is characterized by facial-nerve inflammation (CN-VII) on one side of the face, in the absence of any other disease such as stroke. Bell's palsy occurs on only one side of the face and more than 40,000 Americans are afflicted each year.

Which noninvasive surgical procedure is often performed in patients with trigeminal neuralgia? Glycerol rhizotomy Gamma knife radiosurgery Microvascular decompression Percutaneous radiofrequency rhizotomy

B Gamma knife radiosurgery is a noninvasive surgical procedure in which high doses of radiation are focused on the trigeminal nerve root using stereotactic localization. Glycerol rhizotomy is a percutaneous procedure in which glycerol is injected into the trigeminal cistern. Microvascular decompression involves lifting the artery pressing on the nerve root in the posterior fossa with a wedge of sponge, leading to a removal of pressure at the nerve root or entry zone. Percutaneous radiofrequency rhizotomy is the destruction of sensory fibers by means of low-voltage current.

A patient is admitted to the hospital after sustaining a C7 spinal cord injury. What is the most important nursing intervention during the acute stage of care? Monitoring vital signs Maintaining a patent airway Maintaining proper body alignment Turning and repositioning the patient every two hours

B Initial care for a patient with a C7 spinal cord injury is focused on establishing and maintaining a patent airway and supporting ventilation. Even though the injury is located at C7, spinal edema may extend to the C4 level and cause paralysis of the diaphragm. Therefore the effects and extent of edema are unpredictable, initially necessitating close monitoring of respiratory status. Monitoring the vital signs and maintaining proper body alignment are important nursing interventions but are not as high a priority as maintaining a patent airway. Turning and repositioning the patient every two hours depends on the stability of the spinal cord injury and the status of spinal precautions. A patient with a spinal cord injury may require a specialty bed or device.

The nurse is caring for a patient with poikilothermia. What condition in the patient's medical record likely caused this clinical manifestation? Polyneuropathy Spinal cord injury Spinal cord tumor Cranial nerve disorder

B Poikilothermia is the inability to maintain body temperature. It is one of the manifestations of spinal cord injury. Polyneuropathies may result in weakness of the lower extremities, paresthesia (numbness and tingling), paralysis with muscle incoordination and weakness, stiffness in the jaw and neck, sharp pains in the leg, and ataxia. Spinal cord tumor may result in back pain, coldness, numbness, and tingling in the extremities. Cranial nerve disorders usually result in burning, knifelike, or lightning-like shock in the lips; intense pain, twitching, tinnitus, paralysis of the motor branches of the facial nerve; and drooping of the mouth accompanied by drooling.

A patient, injured at work with an open cut, asks the occupational health nurse whether a "tetanus shot" is needed. The nurse should base the response on which of the following facts? Whether the patient had tetanus in the past. When the patient last received a tetanus toxoid booster. Whether the patient is experiencing any stiffness in the jaw. Whether the patient has received antibiotics in the past six weeks.

B Tetanus is a severe infection resulting from an anaerobic bacterium Clostridium tetani. It has a very high mortality rate and prevention with immunization is the first line of treatment. Adults should receive a tetanus booster every 10 years routinely and receive a booster every five years if an open wound occurs. The nurse should evaluate the patient's medical records to determine if a booster is warranted. Contracting and surviving tetanus are rare. Adequate immunization should prevent the disease so stiffness of the jaws, an early sign of the disease once known as lockjaw, should not occur. Previous treatment with antibiotics is not a factor for determining whether a tetanus booster is indicated.

The nurse is caring for a patient with a spinal cord injury who demonstrates motor paralysis and a loss of pain and temperature sensation below the level of injury. What may be the causative factor of this condition? Damage to the central spinal cord Damage to the anterior spinal artery Damage to the posterior spinal artery Damage to one-half of the spinal cord

B The causative factor for motor paralysis, loss of pain, and temperature sensation is damage to the anterior spinal artery. A damage to the central spinal cord results in motor weakness and sensory loss in the upper and lower extremities. Loss of pain and temperature sensation below the level of injury is caused when one-half of the spinal cord is damaged. Damage to the posterior spinal artery affects the dorsal column, which results in a loss of proprioception.

The nurse is performing a musculoskeletal assessment on the older patient. Which is the mostimportant factor considered by the nurse when performing the musculoskeletal assessment on the older patient? Dietary habits Exercise practices Psychosocial status Present medication list

B To find out the impact of age-related changes, the nurse needs to know what type of exercise, frequency, and warm-up activities the patient does. Even though dietary habits, psychosocial status, and medications are informative, the exercise regimen is the most important factor when performing a musculoskeletal assessment.

The nurse reviews a patient's medical record and notes tic douloureux. The nurse expects what assessment finding? Severe, bilateral pain along the distribution of the trigeminal nerve Recurrent episodes of stabbing pain along the distribution of the trigeminal nerve Cycles of pain along the trigeminal nerve and refractoriness that continues for hours Specific point along the trigeminal nerve that can initiate pain when it is lightly touched

B Trigeminal neuralgia is also referred to as tic douloureux. It is characterized by recurrent episodes of stabbing pain along the distribution of the trigeminal nerve. It is not a severe, bilateral pain but a severe, unilateral pain along the distribution of the nerve. Cycles of pain along the trigeminal nerve and refractoriness that continue for hours are referred to as clustering. The specific point along the trigeminal nerve that can initiate pain when it is lightly touched is called a trigger zone.

The nurse is preparing educational materials about the differences between the facial characteristics of Bell's palsy and those of trigeminal neuralgia. What characteristics of Bell's palsy should the nurse include? Select all that apply. Facial grimacing Unable to whistle Flat nasolabial fold Unable to open the eyelid Frequent tearing of the eye

B, C In Bell's palsy, the muscles innervated by the facial nerve become weak, and the patient is unable to whistle. There is also flattening of the nasolabial fold. The nasolabial folds are commonly known as "smile lines" or "laugh lines." They are the two skin folds that run from each side of the nose to the corners of the mouth. They separate the cheeks from the upper lip. Facial grimacing is a feature of trigeminal neuralgia rather than Bell's palsy. In Bell's palsy, the patient is unable to close the eyelid when closure is attempted. In trigeminal neuralgia, there is frequent tearing of the eye.

A patient who came to the hospital two days ago is diagnosed with Guillain Barré syndrome. Plasmapheresis is planned to treat the condition. What criteria are used to determine if this treatment is effective? Select all that apply. Urinary output is at least 30 mL per hour. Stabilization of blood pressure and pulse rate. Symptoms of paralysis stop progressing and abate. Lung vital capacity and arterial blood gases are stable. Blood urea nitrogen (BUN) and creatinine levels are within normal levels.

B, C, D Guillain Barré syndrome is a polyneuropathic condition resulting from an immune response following some type of infection. Symptoms include paresthesia with ascending bilateral paralysis as demyelination of the nerves occurs. The paralysis starts in the extremities and can advance to the thoracic area, resulting in respiratory failure. Disturbance in the autonomic nervous system causes episodes of hypotension, hypertension, and bradycardia. Treatment is successful with the halt of paralysis and stabilization of cardiovascular function and respiratory status. BUN and creatinine levels and urinary output are measures of renal function.

A patient is diagnosed with tetanus infection. The nurse has to explain the treatment plan for this patient to the caregivers. What are the interventions that would be a part of the treatment plan? Select all that apply. Administration of antiviral drugs Administration of opioid analgesics Administration of sedatives and muscle relaxants Administration of tetanus toxoid and immune globulin Administration of drugs causing neuromuscular excitati

B, C, D The management of tetanus includes administration of a tetanus toxoid, diphtheria toxoid, and pertussis (Tdap) booster and tetanus immune globulin in different sites to neutralize circulating toxins. Opioid analgesics such as morphine or fentanyl are indicated for pain management. Control of spasms is essential and is managed by sedation and skeletal muscle relaxation, usually with diazepam and barbiturates. Drugs causing neuromuscular excitation would worsen the condition, but neuromuscular blocking agents such as vecuronium that act to paralyze skeletal muscles can be given if the condition deteriorates further. This condition is caused by the bacteria Clostridium tetani, which would not be eliminated by administering antiviral drugs.

A nurse is assessing a patient with a T2-level spinal cord injury. The nurse notices that there is a kink in the catheter, the bladder is distended, and the blood pressure is 220/100 mm Hg. What nursing interventions would be appropriate for this patient if the nurse suspects autonomic dysreflexia? Select all that apply. Lower the head of the bed. Monitor blood pressure regularly. Make the patient lie flat on the bed. Notify the primary health care provider. Check for the presence of bowel impaction. Remove the kink in the catheter and drain the bladder.

B, C, D, E A sudden rise in blood pressure for a spinal cord injury patient above the level of T6 is generally indicative of autonomic dysreflexia. Nursing interventions in a serious emergency like autonomic dysreflexia include notifying the primary health care provider and determining the cause. The blood pressure should be regularly monitored; administration of an alpha-adrenergic blocker or an arteriolar vasodilator is required. Contractions of the rectum are also a cause; therefore, the nurse should check for bowel impaction and treat it accordingly. The most common cause is bladder distension. If a catheter is present, the presence of any kinks or folds should be checked. However, the most important nursing intervention in this case is elevating the head of the bed 45 degrees or higher to make the patient sit upright; this would lower the blood pressure.

A woman has had a T4 level complete spinal cord injury (SCI). She wants to know about the impact of this injury on her sexuality. What information and instructions should the nurse tell her regarding her sexuality? Select all that apply. The injury does not cause amenorrhea. Precautions for unplanned pregnancy are necessary. The patient does have the capacity to become pregnant. Erotic and sexual thoughts may not cause vaginal lubrication to take place. Fatal complications like autonomic dysreflexia could be associated with pregnancy.

B, C, D, E The injury does not affect the ability to become pregnant or to deliver normally through the birth canal. If sexual activity is resumed, protection against an unplanned pregnancy is necessary. Women with upper motor neuron injuries may retain the capacity for reflex lubrication, whereas psychogenic lubrication, which is dependent on sexual thought processes, depends on the completeness of injury. A normal pregnancy may be complicated by urinary tract infection (UTI), anemia, and most fatal of all, autonomic dysreflexia. Menses may cease for as long as six months after the spinal cord injury. The woman of childbearing age with an SCI usually remains fertile.

A patient with a T-4 injury develops signs of neurogenic shock. Which assessment findings are expected with this complication? Select all that apply. Tachycardia Bradycardia Hypotension Hypertension Peripheral vasodilation Peripheral vasoconstriction

B, C, E A spinal cord injury above T-6 leads to dysfunction of the sympathetic nervous system, which may result in neurogenic shock, indicated by peripheral vasodilation, bradycardia, and hypotension. Tachycardia, hypertension, and peripheral vasoconstriction typically only occur if the sympathetic system is intact.

A patient with spinal cord injury is paralyzed below the waist. The patient is completely dependent for all care, is withdrawn, and sleeps excessively. The patient states to the nurse, "I can't believe this is happening to me." Which nursing actions are appropriate for this patient? Select all that apply. Show sympathy towards the patient. Encourage the patient to set daily goals. Encourage the patient to participate in care. Explain the injury using written teaching material. Teach the patient what to expect during the rehabilitation period.

B, C, E Appropriate nursing actions include encouraging the patient to participate in care, allowing the patient to make daily goals, and teaching the patient what to expect during the rehabilitation process. Although the nurse should empathize with the patient, sympathy is not a therapeutic action. The use of written material may not be the best way to teach this patient at this time.

A nurse is preparing a teaching plan for a patient with spinal cord injury. What information about nutritional therapy should the nurse include in the plan for the patient and the caregiver? Select all that apply. nclude spicy food to improve taste. Include two servings from the milk group. Eat three well-balanced meals each day. Include beans in the diet to increase fiber intake. Include two or more servings from the meat group.

B, C, E For maintaining adequate nutrition in the patient with spinal cord injury, the nurse should instruct the patient to eat three well-balanced meals per day. Food items should be included from the milk and the meat group to increase protein intake. Beans should be avoided, because they can cause formation of gas. Spicy food should also be avoided, because it can cause gastrointestinal upset.

A patient with spinal cord injury has begun to get stress ulcers. What nursing interventions should be performed for this patient? Select all that apply. Withhold antacids. Check stools for blood. Motivate the patient and provide a stress-free environment. Obtain prescriptions for increased dosage of corticosteroids. Administer proton pump inhibitors for prophylaxis as prescribed.

B, C, E In spinal cord injuries, stress ulcers are an important complication resulting from the physiologic response to severe trauma, the psychologic stress associated with the injury, and treatment with high-dose corticosteroids. The stress ulcers usually appear between 6 to 14 days after injury. Stool and gastric contents should be daily checked for presence of blood. Prophylactic treatment with histamine (H 2)-receptor blockers like ranitidine or proton pump inhibitors like pantoprazole helps in decreasing the secretion of HCl acid and prevents ulcers during the initial phase. Antacids should be given along with corticosteroids to prevent development of stress ulcers.

A patient has a T7-level complete spinal cord injury (SCI). He wishes to discuss the related sexual problems with the nurse. What information and advice regarding sexual dysfunction should the nurse give the patient? Select all that apply. Male fertility will not be affected by the injury. A reflex erection could be easily elicited in the patient. The patient may have erectile dysfunction that can be treated. The patient's ability to have psychogenic erections is not affected. Vacuum suction devices help in improving blood flow to the penis.

B, C, E Men with complete injuries are less likely to experience psychogenic erections. However, most men with SCI are able to have a reflex erection with physical stimulation, regardless of the extent of the injury if the S2-S4 nerve pathways are not damaged. Treatment for erectile dysfunction includes drugs, vacuum devices, and surgical procedures. If sildenafil (Viagra) fails to improve erectile dysfunction, vacuum suction devices use negative pressure to encourage blood flow into the penis. Male fertility is affected by SCI, causing poor sperm quality and ejaculatory dysfunction.

A patient is suspected of having cervical cord injury following a motor vehicle accident. Which nursing interventions are appropriate for this patient to stabilize the cervical spine? Select all that apply. Avoid "logrolling" of the patient. Ensure that the patient's body is correctly aligned. Use a sternal-occipital-mandibular immobilizer brace. Use a soft cervical collar to stabilize the cervical spine. Use a firm backboard to prevent any spinal movement.

B, C, E Proper immobilization of the neck involves the maintenance of a neutral position. This can be obtained by use of a hard cervical collar and a backboard to stabilize the neck to prevent lateral rotation of the cervical spine. The nurse should ensure that the body is always correctly aligned. The patient can also use a sternal-occipital-mandibular immobilizer brace. A soft collar is not sufficient to immobilize the cervical spine. When turning the patient, the patient's body should be moved as a unit (i.e., "logrolling") to prevent movement of the spine.

A patient with spinal cord injury has to be catheterized. Which nursing interventions will help to prevent urinary tract infection (UTI)? Select all that apply. Empty the urine bag whenever it is 25 percent filled. Ensure regular and complete drainage of the bladder. Start intermittent catheterization once the patient is stabilized. Maintain the urine drainage bag above the level of the bladder. Cleanse the patient's genitalia using antiseptic before placing the catheter.

B, C, E UTIs are a common problem in patients with spinal cord injuries. The best method for preventing UTIs is regular and complete bladder drainage. After the patient is stabilized, the best means of managing long-term urinary function should be assessed. Usually the patient is started on an intermittent catheterization program. The other common yet important intervention that a nurse could utilize is to use aseptic methods while inserting the catheter, like cleaning the genitalia using antiseptic. The urine bag should be drained every eight hours or when filled about two thirds. When catheterized for a long period, the urine bag should be kept below the level of the bladder; this will prevent backflow of urine and guard against infections.

A patient with a T1-level spinal cord injury is soon to be discharged from the hospital. The nurse has to plan the home care for neurogenic bowel management. What should the nurse include in the care plan? Select all that apply. Teach the Valsalva maneuver. Explain the use of stool softeners. Advise the patient to eat a high-fiber diet. Advise the patient to limit fluids in the diet. Teach the patient how to use suppositories for evacuation. Teach the patient to perform digital stimulation of the rectum.

B, C, E, F Careful management of bowel evacuation is necessary in the patient with spinal cord injury (SCI) because voluntary control of this function may be lost. This condition is called neurogenic bowel. A stool softener such as docusate sodium can be used to regulate stool consistency. A digital stimulation (performed 20 to 30 minutes after suppository insertion) by the nurse or patient may be necessary. In addition, suppositories (bisacodyl or glycerin) or small-volume enemas can be used. The usual measures for preventing constipation include a high-fiber diet and adequate fluid intake. However, these measures by themselves may not be adequate to stimulate evacuation. The Valsalva maneuver requires intact abdominal muscles, so it is used in those patients with injuries below T12. A high intake of fluid is advised for easier bowel evacuation.

The nurse recognizes that which medications are considered to be first-line drugs for treatment of trigeminal neuralgia? Select all that apply. Baclofen Phenytoin Topiramate Gabapentin Clonazepam Carbamazepine

B, C, E, F Phenytoin, topiramate, clonazepam, and carbamazepine are first-line drug therapies for trigeminal neuralgia. These are antiseizure drugs that may reduce pain by stabilizing the neuronal membrane and blocking nerve firing. Baclofen or gabapentin may be used in combination with any of the antiseizure drugs if a single drug is not effective.

The patient with trigeminal neuralgia asks the nurse about the incidence and how this condition is diagnosed. Which responses by the nurse are most accurate? Select all that apply. "It occurs twice as often in men than women." "90% of the cases occur in people over age 50." "It is one of the most commonly diagnosed neuralgic conditions." "Risk factors include rheumatoid arthritis and primary epilepsy." "The cause and physical aspects of trigeminal neuralgia are not well known." "Every year, about 12 in 100,000 Americans are diagnosed with this condition."

B, C, E, F Trigeminal neuralgia is a common neuralgic condition with poorly known etiology and pathology that generally occurs in people over age 50. Each year about 12 in 100,000 Americans are diagnosed with this condition. The disease occurs more often in women than men. Risk factors include patients with herpesvirus infections, infection of the teeth and jaw, and brain stem infarct.

The patient with trigeminal neuralgia asks the nurse about the incidence and how this condition is diagnosed. Which responses by the nurse are mostaccurate? Select all that apply. "It occurs twice as often in men than women." "90% of the cases occur in people over age 50." "It is one of the most commonly diagnosed neuralgic conditions." "Risk factors include rheumatoid arthritis and primary epilepsy." "The cause and physical aspects of trigeminal neuralgia are not well known." "Every year, about 12 in 100,000 Americans are diagnosed with this condition."

B, C, E, F Trigeminal neuralgia is a common neuralgic condition with poorly known etiology and pathology that generally occurs in people over age 50. Each year about 12 in 100,000 Americans are diagnosed with this condition. The disease occurs more often in women than men. Risk factors include patients with herpesvirus infections, infection of the teeth and jaw, and brain stem infarct.

A patient has had two episodes of trigeminal neuralgia and has lately been exhibiting strange mannerisms. The nurse identifies them to be coping strategies to avoid another episode. What observed mannerisms would have led the nurse to conclude this? Select all that apply Patient avoids sleeping. Patient has stopped eating. Patient avoids blinking the eye. Patient covers the face with a cloth. Patient avoids interacting with people.

B, D, E A triggering mechanism can initiate painful episodes in trigeminal neuralgia. The triggers may include a light touch at a specific point along the distribution of the nerve branches. It can be precipitated by chewing, tooth brushing, feeling a hot or cold blast of air on the face, washing the face, yawning, or even talking. Therefore the patient may avoid these activities to prevent painful episodes. As a result, the patient may not chew food and may eat improperly, may cover the face with a cloth, and may withdraw from interaction with other individuals. The patient may sleep excessively as a means of coping with the pain. Movement of eyes does not trigger a painful episode.

A patient has had two episodes of trigeminal neuralgia and has lately been exhibiting strange mannerisms. The nurse identifies them to be coping strategies to avoid another episode. What observed mannerisms would have led the nurse to conclude this? Select all that apply. Patient avoids sleeping. Patient has stopped eating. Patient avoids blinking the eye. Patient covers the face with a cloth. Patient avoids interacting with people.

B, D, E A triggering mechanism can initiate painful episodes in trigeminal neuralgia. The triggers may include a light touch at a specific point along the distribution of the nerve branches. It can be precipitated by chewing, tooth brushing, feeling a hot or cold blast of air on the face, washing the face, yawning, or even talking. Therefore the patient may avoid these activities to prevent painful episodes. As a result, the patient may not chew food and may eat improperly, may cover the face with a cloth, and may withdraw from interaction with other individuals. The patient may sleep excessively as a means of coping with the pain. Movement of eyes does not trigger a painful episode.

The nurse is performing a physical assessment of a patient with Bell's palsy. What clinical manifestations is the nurse likely to find? Select all that apply. Narrowed palpebral fissure Flattening of the nasolabial fold Grimacing and frequent blinking Flaccidity of the affected side of the face Drooping of the mouth accompanied by drooling

B, D, E Bell's palsy is characterized by inflammation of the facial nerve (CN VII) on one side of the face in the absence of any other disease such as a stroke. Paralysis of the motor branches of the facial nerve typically results in flaccidity of the affected side of the face, with drooping of the mouth accompanied by drooling. Nasolabial folds may flatten due to facial nerve inflammation and its impact on the muscle. Grimacing and frequent blinking are clinical manifestations of trigeminal neuralgia and not Bell's palsy. The patient may also have a widened palpebral fissure, not narrowed palpebral fissures.

A patient has been diagnosed with botulism. The nurse is explaining to the patient and the caregivers about the pathology involved in the disease. What points should the nurse emphasize while explaining it? Select all that apply. Botulism is a water-borne disease. The spores of the organism are difficult to destroy. This neurotoxin damages the gray matter of the brain. This neurotoxin inhibits nerve impulses from reaching the muscle. The neurotoxin produced by the bacteria is absorbed in the gastrointestinal (GI) tract.

B, D, E Botulism is caused by GI absorption of the neurotoxin produced by Clostridium botulinum. The neurotoxin destroys or inhibits the neurotransmission of acetylcholine at the myoneural junction, resulting in disturbed muscle innervation. This organism is found in the soil, and the spores are difficult to destroy. Botulism is rare but is the most serious type of food poisoning; it is not a water-borne disease. The neurotoxin affects the myoneural junction and not the nerve cell bodies, and so the grey matter of the brain is not damaged in this condition

The nurse that is caring for a patient with Bell's palsy should monitor for what complications? Select all that apply. Weight gain Corneal abrasions Respiratory failure Psychologic withdrawal Mucous membrane trauma

B, D, E Complications of Bell's palsy include corneal abrasions, psychologic withdrawal, and mucous membrane trauma. Instead of weight gain, the patient may have malnutrition. Respiratory failure is a common complication of Guillain-Barre syndrome (GBS) rather than of Bell's palsy.

The nurse is caring for a patient with Guillain-Barré syndrome. What signs and symptoms should the nurse continuously monitor for in this patient? Select all that apply. Continuous tonic seizures Presence of bed sores Stiffness in the jaw and neck Changes in bladder function Respiratory rate and rhythm

B, D, E Immobility from the paralysis can cause problems such as bed sores. Bladder function may be disrupted due to urinary tract infection. The most serious complication is respiratory failure, which occurs as the paralysis progresses to the nerves that innervate the thoracic area. Constant monitoring of the respiratory system by checking respiratory rate and depth provides information about the need for immediate intervention, including intubation and mechanical ventilation. Continuous tonic seizures and stiffness in the jaw do not occur in Guillain-Barré syndrome. These are manifestations of tetanus.

A patient has been admitted to the hospital with a spinal cord injury. Following the assessment, the health care provider concludes that the injury is above T12. What signs and symptoms related to the gastrointestinal system would indicate an injury above T12? Select all that apply. The patient has an absence of bowel sounds. There is excess gastric distention, and the stomach is hard. The patient is constipated and is passing hard stools with straining. The sensation of a full bowel is perceived by the patient, and fecal incontinence is present. The sensation of a full bowel is not perceived by the patient, and fecal incontinence is present.

B, E An injury above T12 leads to development of a reflexic bowel, wherein nervous interactions between the colon (large intestine) and the brain are interrupted. As a result, the person may not feel the need to have a bowel movement. However, stool is still building up in the rectum. The build-up triggers a reflex, causing the rectum and colon to react, leading to a bowel movement without warning. When the sensation of a full bowel is perceived by the patient and the patient has fecal incontinence, it is a lower-level spinal cord injury (below T12). In spinal cord injury, it is usually incontinence that occurs. When the injury is above T5, paralytic ileus may be present and bowel sounds may be absent.

A patient has been admitted with T2-level spinal cord injury and has abnormal cardiovascular signs and symptoms. Which drugs should the nurse administer to stabilize the condition of this patient? Select all that apply. Digoxin Atropine Metoclopramide Vasodilator drugs Vasopressor drugs

B, E Due to the spinal cord injury at the T2 level, the patient may have abnormal cardiac signs and symptoms like bradycardia, peripheral vasodilation, and hypotension. Atropine should be administered to increase the heart rate and prevent hypoxemia. Hypotension should be treated by administering IV fluids or vasopressor drugs. Vasodilators would accentuate the peripheral pooling of blood, thereby worsening the condition. Digoxin is used to treat arrhythmias like ventricular tachycardia, and they act by reducing the heart rate. The patient has bradycardia, so digoxin administration would worsen the condition. Metoclopramide is not given for cardiac condition; it is used to treat delayed gastric emptying.

A patient's surgical therapy for trigeminal neuralgia resulted in an altered corneal reflex. The nurse provides education about long-term management of the reflex. Which statements made by the patient indicate the need for further teaching? Select all that apply. "I will examine my eyes regularly." "I will go for an annual dental visit." "I will check my oral cavity after meals." "I will chew food on the unaffected side." "I will avoid ice cream and cold beverages."

B, E If the patient says that an annual dental visit is needed, then there is need for further teaching. The nurse should teach the patient to have semi-annual dental visits. There is no need to avoid ice creams and cold beverages. However, hot food and beverages should be avoided, because these can burn the mucous membrane. The patient needs to examine his or her eyes regularly for symptoms of infection or irritation. The oral cavity should be checked after meals to remove residual food particles. The patient should chew food on the unaffected side of the mouth.

The nurse would assess for trigeminal neuralgia in patients with which conditions? Select all that apply. Hypotension Multiple sclerosis Viral immunization Food contamination Herpesvirus infection

B, E Multiple sclerosis and herpesvirus infection are conditions associated with trigeminal neuralgia. Hypertension, rather than hypotension, is associated with trigeminal neuralgia. Viral immunizations may put patients at risk for Guillain-Barre syndrome (GBS). Food contaminated with Clostridium botulinum may increase risk for botulism.

A patient asks the nurse about the differences between trigeminal neuralgia and Bell's palsy. What symptoms of trigeminal neuralgia should the nurse include in the teaching? Select all that apply. Hearing deficits Tearing of the eye Pain behind the ear Drooping of the mouth Pain on the side of the nose

B, E Trigeminal neuralgia may cause tearing of the eye during an acute attack. This is not seen in patients with Bell's palsy. Trigeminal neuralgia may also cause excruciating pain described as a burning, knifelike, or lightning-like shock on parts of the face including the side of the nose. In patients with Bell's palsy, pain may be present behind the ear on the affected side, especially before the onset of paralysis. Drooping of the mouth is a feature of Bell's palsy, not trigeminal neuralgia. Although alterations in sensory functions may occur with both trigeminal neuralgia and Bell's palsy, there are differences. Patients with trigeminal neuralgia may experience facial sensory loss, whereas patients with Bell's palsy may have hearing deficits or unilateral loss of taste sensations.

Which cranial nerve does the nurse know is associated with tic douloureux? I III V VII

C Cranial nerve V is the trigeminal nerve, which is involved with trigeminal neuralgia, also known as tic douloureux. Most cases result from vascular compression of the trigeminal nerve root by an abnormal loop of the superior cerebral artery. Cranial nerve I is the olfactory nerve, which is responsible for the sense of smell. Cranial nerve III is the oculomotor nerve, which is responsible for raising eyelids, moving eyes, regulating the size of pupils, and focusing lenses. Cranial nerve VII is the facial nerve, which is responsible for facial expression and taste.

A patient is diagnosed with Bell palsy. Which cranial nerve does the nurse teach the patient is associated with the disorder? II V VII XII

C Cranial nerve VII is the facial nerve; when it becomes inflamed, it is responsible for Bell palsy, a paralysis or weakness of the muscles on one side of the face. Cranial nerve II is the optic nerve associated with vision. Cranial nerve V is the trigeminal nerve, which is associated with sensation of the face and motor functions such as biting and chewing. Cranial nerve XII is the hypoglossal nerve, which is responsible for tongue movement.

The nurse differentiates between the clinical manifestations of Guillain-Barre syndrome (GBS) that are related to autonomic nervous system dysfunction and those that are related to cranial nerve involvement. What does the nurse identify as a clinical manifestation that is related to the autonomic nervous system? Dysphagia Tachycardia Facial flushing Facial weakness

C Facial flushing is a manifestation of Guillain-Barre syndrome (GBS) that results from autonomic nervous system dysfunction. Dysphagia occurs due to cranial nerve involvement. Autonomic nervous system dysfunction causes bradycardia, rather than tachycardia in patients with Guillain-Barre syndrome (GBS). Facial weakness is a result of cranial nerve involvement.

What health promotion activity will have the greatest impact in the prevention of spinal cord injury (SCI) in adults 65 years and older? Hearing testing Depression screenings Fall prevention strategies Monitoring blood pressure

C Falls are the leading cause of SCI in persons 65 years and older. Teaching patients to avoid climbing and using handrails on stairs are ways to prevent falls and injury. Hearing testing, depression screening, and blood pressure monitoring are all ways to promote the health of persons 65 and older, but do not prevent SCI directly.

The nurse is preparing educational materials about Guillain-Barre syndrome (GBS) and Bell's palsy. How is GBS different than Bell's palsy? GBS affects cranial nerves. GBS is a mononeuropathy. GBS is a potentially fatal disorder. GBS results in demyelination of the nerve.

C Guillain-Barre syndrome (GBS) is a rapidly progressing and potentially fatal disorder. Bell's palsy is a benign disorder in which full recovery may occur in three to six months. Both disorders affect cranial nerves. Guillain-Barre syndrome (GBS) also affects the peripheral nervous system and is a polyneuropathy. Bell's palsy is a mononeuropathy. Both disorders may result in demyelination of the involved nerve.

What body system is the major focus for nursing care of the patient with Guillain-Barré syndrome? Urinary Cardiac Respiratory Gastrointestinal

C Guillain-Barré syndrome is an autoimmune disease that destroys the myelin sheath covering peripheral nerves. Symptoms range from mild to severe, potentially as far as full-body paralysis. Frequently the muscles controlling respiratory function are affected, resulting in respiratory failure. The disease causes rapid, progressive, symmetrical loss of motor function that ascends from the extremities to the head. Although Guillain-Barré syndrome may affect some functions of the urinary, cardiac, and gastrointestinal systems, respiratory status is most important for the nurse to monitor

The oral intake of a patient with trigeminal neuralgia is sharply reduced, and the patient's nutritional status is compromised. What is the priority nursing intervention? Serving lukewarm food Ensuring that the food is easy to chew Providing food through a nasogastric tube Encouraging intake of foods high in protein

C If the nutritional status of the patient is compromised due to a sharp reduction of oral intake, the priority intervention should be to provide enteral feedings through a nasogastric tube. Once a reasonable amount of nutrition is restored and the patient is able to feed orally, food should be served lukewarm and at frequent intervals. After the patient can eat normally, food should be easy to chew and high in protein content. Until then, nasogastric feedings are indicated to facilitate a return to homeostasis.

The nurse is providing care for a patient who has been diagnosed with Guillain-Barré syndrome. Which assessment should be the nurse's priority ? Pain assessment Glasgow coma scale Respiratory assessment Musculoskeletal assessment

C In the care of patients with Guillain-Barré syndrome, the acute risk of respiratory failure necessitates vigilant monitoring of the patient's respiratory status. Pain and musculoskeletal assessment are important for the patient with Guillain-Barré syndrome, but are not a priority. The Glasgow coma scale also is important in assessing the neurologic status of the patient, but it is not a priority.

The nurse caring for a patient with Bell's palsy expects to find which distinctive symptom on assessment? Facial pain Slurred speech An eye that will not blink Sagging of facial muscles

C The nonblinking eye is a cardinal sign of Bell's palsy. Facial pain, slurred speech, and sagging facial muscles are not exclusively symptoms of Bell's palsy. Facial pain may be observed in trigeminal neuralgia. Slurred speech and sagging facial muscles are commonly seen with cerebrovascular accident.

A patient with spinal cord injury is suspected of having deep vein thrombosis. The health care provider advises the nurse to administer low-molecular-weight heparin. What should the nurse assess before initial administration of the drug? Select all that apply. Gastroenteritis Signs of any infection Signs of any internal bleeding Any history of recent surgeries Signs of any respiratory distress

C, D Low-molecular-weight heparin (e.g., enoxaparin) is used to prevent venous thromboembolism unless contraindicated. Contraindications include internal bleeding and recent surgery. Low-weight heparin can be administered in the presence of any infection, respiratory problems, or gastroenteritis.

The patient with peripheral facial paresis on the left side of the face is diagnosed with Bell's palsy. What should the nurse include in teaching the patient about self-care? Select all that apply. Administration of antiseizure medications Preparing for a nerve block to relieve pain Administration of corticosteroid medications Dark glasses and artificial tears to protect the eyes Surgeries available if conservative therapy is not effective

C, D Self-care for Bell's palsy includes corticosteroid medications to decrease inflammation of the facial nerve (CN VII) and protecting the cornea from drying out because of the inability to close the eyelid. Antiseizure medications, a nerve block, or surgeries are used for trigeminal neuralgia, not Bell's palsy

A patient with a spinal cord injury has a neurogenic bowel. Beyond the use of bisacodyl suppositories and digital stimulation, which measures should the nurse teach the patient and the caregiver about to assist the patient with bowel evacuation? Select all that apply. rink more milk Use oral laxatives every day Eat 20 to 30 g of fiber per day Drink 1800 to 2800 mL of water or juice Establish bowel evacuation time at bedtime

C, D The patient with a spinal cord injury and neurogenic bowel should eat 20 to 30 g of fiber and drink 1800 to 2800 mL of water or juice each day. Milk may cause constipation. Daily oral laxatives may cause diarrhea and are avoided unless necessary. Bowel evacuation time usually is established 30 minutes after the first meal of the day to take advantage of the gastrocolic reflex induced by eating.

A patient with a spinal cord injury (SCI) at the level of the seventh cervical vertebra (C7) has experienced episodes of autonomic dysreflexia. What signs and symptoms occur with this condition? Select all that apply Involuntary stool Severe drop in blood pressure Sudden onset of severe headache Sweating above the level of the SCI Flushed face and chest above the level of the SCI

C, D, E Autonomic dysreflexia is a condition that can occur in persons with SCI at the level of the sixth thoracic vertebra (T6) or higher. A sensory receptor (as with a distended bladder) is stimulated below the level of injury and the sympathetic nervous system responds with vasoconstriction. This is not mediated by the parasympathetic nervous system, but caused by the SCI. Thus the patient develops severe hypertension, often with bradycardia. The causative factors also include rectal distension or skin stimulation. The causative factor must be alleviated as soon as possible. The sympathetic stimulation causes flushing of the face and sweating above the site of the SCI. The rapid rise in blood pressure gives the patient a severe headache. The patient does not have bowel function, so an involuntary bowel movement will not occur. The condition causes severe hypertension, not hypotension.

A patient with a spinal cord injury (SCI) at the level of the seventh cervical vertebra (C7) has experienced episodes of autonomic dysreflexia. What signs and symptoms occur with this condition? Select all that apply. Involuntary stool Severe drop in blood pressure Sudden onset of severe headache Sweating above the level of the SCI Flushed face and chest above the level of the SCI

C, D, E Autonomic dysreflexia is a condition that can occur in persons with SCI at the level of the sixth thoracic vertebra (T6) or higher. A sensory receptor (as with a distended bladder) is stimulated below the level of injury and the sympathetic nervous system responds with vasoconstriction. This is not mediated by the parasympathetic nervous system, but caused by the SCI. Thus the patient develops severe hypertension, often with bradycardia. The causative factors also include rectal distension or skin stimulation. The causative factor must be alleviated as soon as possible. The sympathetic stimulation causes flushing of the face and sweating above the site of the SCI. The rapid rise in blood pressure gives the patient a severe headache. The patient does not have bowel function, so an involuntary bowel movement will not occur. The condition causes severe hypertension, not hypotension.

A patient has had three episodes of trigeminal neuralgia and has stopped eating food, fearing that chewing would trigger pain. What advice should the nurse give that would help to maintain a proper nutritional status of this patient? Select all that apply. Advise the patient to eat food that is hot. Encourage the patient to limit fluid intake. Advise the patient to consume food that is easy to chew. Advise the patient to eat small quantities of food more frequently. Advise the patient to eat food that is rich in carbohydrates and proteins.

C, D, E Chewing food could predispose the patient to an episode of trigeminal neuralgia; therefore in anticipation of an episode, the patient may stop eating. In such a case, the nurse should advise the patient to consume food that is easy to chew. Food should be high in protein and calories to meet nutritional demand. Small meals should be taken more frequently. Encourage the patient to take adequate amounts of fluids, because they do not require chewing. Food should be served lukewarm so that it becomes easier to chew.

A patient has been admitted to the hospital with spinal cord injury at the upper thoracic level. The health care provider informs the caregiver that the patient is in a state of neurogenic shock. How should the nurse explain the term neurogenic shock to the caregivers? Select all that apply. Blood pressure and heart rate have increased. Blood vessels in the extremities have constricted. There is loss of nervous control of the blood vessels. The amount of blood pumped out of the heart reduces. There is pooling of blood in the veins of the extremities.

C, D, E Neurogenic shock is due to the loss of vasomotor tone caused by spinal cord injury. Loss of sympathetic nervous system innervation causes peripheral vasodilation, venous pooling, and decreased cardiac output. It is chiefly characterized by hypotension and bradycardia, not increased blood pressure and heart rate. The blood vessels in the extremities dilate due to neurogenic shock.

A percutaneous radiofrequency rhizotomy procedure has been planned for a patient with trigeminal neuralgia. What information should the nurse give to this patient about the procedure? Select all that apply. Patient will be well-sedated during this procedure. A small craniotomy will be performed behind the ear. Patient may experience facial numbness after the surgery. Patient may have difficulty with eye movements after the procedure. Patient may have difficulty in masticating effectively for some time after the procedure.

C, D, E Percutaneous radiofrequency rhizotomy is an outpatient procedure consisting of placing a needle into the trigeminal rootlets that are adjacent to the pons and destroying the area by means of a radiofrequency current. This can result in facial numbness, corneal anesthesia (resulting in difficulty in eye movement), and trigeminal motor weakness. The trigeminal nerve supplies the muscles involved in mastication; therefore the surgery may affect mastication. Patients need to know that they will be awake during local procedures so that they can cooperate when corneal and ciliary reflexes and facial sensations are checked. A craniotomy is not required for this procedure, because it only involves placing a needle. A craniotomy is required in microvascular decompression of the trigeminal nerve.

A patient has been diagnosed with trigeminal neuralgia. For which etiologic factors should the nurse assess the patient? Select all that apply. Sarcoidosis Lyme disease Brainstem infarct Herpes virus infection Infection of the teeth and jaw

C, D, E The etiologic factors of trigeminal neuralgia include herpesvirus infection, infection of the teeth and jaw, and brainstem infarct. Sarcoidosis and Lyme disease do not cause trigeminal neuralgia; they are etiologic factors for Bell's palsy.

The respiratory status of a patient with Guillain-Barré syndrome is deteriorating. What nursing interventions should be performed for this patient? Select all that apply. Obtain prescription for steroid inhaler. Administer bronchodilators, as prescribed. Check for fever, and send for sputum culture. Keep necessary equipment ready for mechanical ventilation and tracheostomy. Regular pulmonary functions tests and arterial blood gas (ABG) should be taken.

C, D, E This patient is highly likely to develop respiratory infections. If fever develops, obtain sputum cultures to identify the pathogen. Appropriate antibiotic therapy is then initiated. The most serious complication is respiratory failure, which occurs as the paralysis progresses to the nerves that innervate the thoracic area. Monitoring the vital capacity and ABGs is essential. If the vital capacity drops to less than 800 mL or the ABGs deteriorate, endotracheal intubation or tracheostomy may be done so that the patient can be mechanically ventilated. Administration of bronchodilators or steroids will not improve the condition of the patient, because the respiratory failure is being caused by the paralysis of respiratory muscles.

A patient having trigeminal neuralgia has been prescribed antiseizure drugs. The patient asks the nurse about how the drug would prevent painful episodes. What explanation should the nurse give in order to explain the mechanism of action of the drug? It blocks the perception of pain sensation. It reduces the pain by treating underlying depression. It anesthetizes the area supplied by the trigeminal nerve. It attenuates the transmission of nerve impulses from the trigeminal nerve.

D Antiseizure drug therapy may reduce pain by stabilizing the neuronal membrane and blocking nerve firing. These drugs do not block the perception of pain sensation like opioids, nor do these drugs anesthetize the area supplied by the trigeminal nerve. These drugs do not act as antidepressants.

A person is injured in a motor vehicle accident and is brought into the emergency department. Which action by the nurse will limit the damage if a spinal cord injury (SCI) has occurred? Initiation of intravenous access peripherally. Maintenance of an open airway using the head tilt method. Determination if the patient is oriented to person, place, and time. Applying a rigid cervical collar and using a backboard to transport the patient.

D Application of a rigid neck collar and use of a backboard will immobilize and stabilize the cervical spine to limit immediate injury to the spinal cord. Initiation of intravenous access is important but is not directly associated with limiting the SCI. Patient orientation will not stabilize a SCI. The airway must be maintained with the jaw thrust technique if SCI is suspected.

When providing care to a patient on a neurologic unit, the nurse notes that the patient is experiencing areflexia. Which diagnosis does the nurse anticipate for this patient? Tetanus Botulism Neurosyphilis Guillain-Barré syndrome

D Areflexia is a clinical manifestation of Guillain-Barré syndrome. Areflexia occurs because of demyelination, edema, and inflammation of the nerves. The expected clinical manifestations of tetanus include trismus (stiffness of the jaw), neck stiffness, and signs of infection such as fever. Clinical manifestations associated with botulism include descending paralysis with muscle incoordination and weakness, difficulty swallowing, seizures, and respiratory muscle weakness. Neurosyphilis, which is caused by Treponema pallidum, manifests as vague, sharp pain in the leg, ataxia, a slapping gait, a loss of proprioception and deep tendon reflexes, and zones of hyperesthesia.

A patient develops Bell's palsy weeks after being diagnosed with a middle ear infection. What explanation should the nurse give when asked about the cause of the condition? A blood clot causes a small stroke, affecting the facial muscles. The eustachian tube becomes blocked, leading to a bulging eardrum. The flow of cerebrospinal fluid (CSF) in the brain is blocked temporarily. A virus causes inflammation, which leads to paralysis of the facial nerve.

D Bell's palsy, or peripheral facial paralysis, causes mouth droop and the inability to close the eyelid, usually on one side. A viral infection is thought to cause inflammation and eventually demyelination of the nerve. Most patients recover fully with treatment within three to six months. Facial weakness, which occurs with a stroke, is caused by a blood clot stopping blood flow to the area of the brain. An inflamed eustachian tube can block drainage from the middle ear, leading to otitis media, a middle ear infection. The flow of CSF is normally blocked temporarily whenever there is an increase in intraabdominal pressure, as with coughing.

The nurse is providing care to a patient with a spinal cord injury as the result of a motor vehicle accident. The nurse notes that the patient feels no pain in the leg on the side opposite the injury. Which spinal cord syndrome does the nurse suspect based on the assessment data? Central cord syndrome Anterior cord syndrome Cauda equina syndrome Brown-Séquard syndrome

D Brown-Séquard syndrome results from damage to one half of the spinal cord. A contralateral (opposite side of the injury) loss of pain and temperature sensation below the level of the injury is a manifestation of the syndrome. Central cord syndrome is caused by damage to the central spinal cord. Motor weakness and sensory loss are the common manifestations of this syndrome. Anterior cord syndrome is caused by damage to the anterior spinal artery and often results in motor paralysis and loss of temperature and pain sensation below the level of the injury. Cauda Equina syndrome results from damage to the lowest portion of the spinal cord. Flaccid paralysis of the lower limbs and areflexic bladder and bowel are the common manifestations.

The nurse is providing care to a patient with a penetrating spinal cord injury. The patient has ipsilateral loss of motor function and position and vibratory sense vasomotor paralysis. Which syndrome does the nurse document in this client? Central cord syndrome Anterior cord syndrome Posterior cord syndrome Brown-Séquard syndrome

D Brown-Séquard syndrome results from damage to one half of the spinal cord. This syndrome is typically caused by a penetrating spinal cord injury and results in a loss of motor function on the same side as the injury. Central cord syndrome is caused by damage to the central spinal cord, resulting in motor weakness and sensory loss in both the upper and lower extremities. Anterior cord syndrome is caused by damage to the anterior spinal artery that results in compromised blood flow to the anterior spinal cord. Motor paralysis and loss of pain and temperature sensation are manifestations. Posterior cord syndrome results from damage or compression to the posterior spinal artery. It is a rare condition that manifests as loss of proprioception.

The nurse is providing care to a patient with trigeminal neuralgia. Which first-line drug prescribed to this patient does the nurse prepare to administer? Baclofen Gabapentin Amitriptyline Carbamazepine

D Carbamazepine is a first-line drug used in the treatment of trigeminal neuralgia. It is an anticonvulsant. Baclofen is a γ-aminobutyric acid receptor agonist used in combination with antiseizure drugs if a single agent is not effective. Amitriptyline is a tricyclic antidepressant that is used to treat constant burning or aching pain, which are manifestations of trigeminal neuralgia. Gabapentin is used as an anticonvulsant and analgesic. It is also used in combination with antiseizure drugs if a single drug is not effective.

The nurse is providing care to a patient with a spinal cord injury who has areflexic bladder. Which syndrome does the nurse anticipate? Central cord syndrome Posterior cord syndrome Brown-Séquard syndrome Conus medullaris syndrome

D Conus medullaris syndrome results from damage to the conus, the lowest part of the spinal cord; it causes flaccid paralysis of the lower limbs and areflexic bladder and bowels. Central cord syndrome is caused by damage to the central spinal cord; it results in motor weakness and sensory loss in the upper and lower extremities. Posterior cord syndrome results from damage to the posterior spinal artery; it usually results in a loss of proprioception. Brown-Séquard syndrome is caused by damage to one half of the spinal cord; it results in ipsilateral and contralateral paralysis.

Which diagnostic study is used to assess soft tissue injury and neurologic changes? Doppler ultrasound Cervical radiography Computed tomographic (CT) scan Magnetic resonance imaging (MRI)

D MRI is used to assess soft tissue injury and neurologic changes. A cervical radiograph is used when a CT scan is not readily available. Doppler ultrasound is used to diagnose deep vein thrombosis. A CT scan is used to diagnose the location and degree of injury and the degree of spinal canal compromise.

When planning care for a patient with a C5 spinal cord injury, which nursing diagnosis has the highestpriority ? Risk for impairment of tissue integrity caused by paralysis Altered patterns of urinary elimination caused by tetraplegia Altered family and individual coping caused by the extent of trauma Ineffective airway clearance caused by high cervical spinal cord injury

D Maintaining a patent airway is the most important goal for a patient with a high cervical fracture. Although the risk for impairment of tissue integrity, altered patterns of urinary elimination, and altered family and individual coping are appropriate nursing diagnoses for a patient with a spinal cord injury, respiratory needs are always the highest priority. Remember airway, breathing, and circulation (ABCs).

The nurse provides preoperative information to a patient with trigeminal neuralgia. The nurse explains that the surgery involves destruction of the sensory fibers of the trigeminal nerve using low-voltage current. What surgery is planned for the patient? Glycerol rhizotomy Gamma knife radiosurgery Microvascular decompression Percutaneous radiofrequency rhizotomy

D Percutaneous radiofrequency rhizotomy is an intracranial procedure that involves the destruction of sensory fibers by low-voltage current. Glycerol rhizotomy is a peripheral procedure in which glycerol is injected into one or more branches of the trigeminal nerve to cause chemical ablation. Gamma knife radiosurgery is an intracranial technique that uses high doses of radiation focused on the trigeminal nerve root using stereotactic localization. Microvascular decompression is an intracranial procedure in which the artery pressing on the nerve root is lifted up and repositioned.

After learning about rehabilitation for a spinal cord tumor, which statement shows that the patient understands what rehabilitation is and can do for him or her? "I want to be rehabilitated for my daughter's wedding in two weeks." "Rehabilitation will be more work done by me alone to try to get better." "I will be able to do all my normal activities after I go through rehabilitation." "With rehabilitation, I will be able to function at my highest level of wellness."

D Rehabilitation is an interdisciplinary endeavor carried out with a team approach to teach and enable the patient to function at the patient's highest level of wellness and adjustment. It will be a lot of work for all involved and takes longer than two weeks. With neurologic dysfunction, the patient will not be able to do all the normal activities in the same way as before the lesion, so this statement should be discussed.

A patient with Guillain-Barré syndrome is admitted to the medical-surgical floor. What does the nurse understand regarding this disorder? Pain is generally worse during the day. It affects males twice as often as females. Heart failure (HF) is the most serious complication of this condition. Patients also may have syndrome of inappropriate antidiuretic hormone (SIADH).

D Syndrome of SIADH also can occur in patients with Guillain-Barré syndrome. The pain, which is manifested by paresthesias, generally is worse at night and the most serious complication is respiratory failure. Guillain-Barré syndrome affects males 1.5 times more frequently than females

A patient diagnosed with Guillain-Barré syndrome has a weak gag reflex. For which complication associated with a weak gag reflex should the nurse intervene? Severe vomiting Difficulty breathing Impaired taste sensations Aspiration of food into the airways

D The gag reflex is a protective mechanism of the body to prevent anything from entering the respiratory tract via the throat. Therefore, a weak gag reflex may cause aspiration, and the nurse should be watchful for this condition. In addition to testing for the gag reflex, the nurse should note drooling and other difficulties with secretions that may indicate an inadequate gag reflex. Manually eliciting a strong gag reflex may cause vomiting. The nurse should intervene if the patient has severe vomiting, difficulty breathing, or impaired taste sensation; however, these symptoms are not caused by a weak gag reflex.

Which of the following assessment findings demonstrates effective use of carbamazepine in the patient with trigeminal neuralgia? Less difficulty swallowing. Ability to close both eyes. Presence of the corneal reflex. Less frequent and severe facial pain.

D Trigeminal neuralgia is very severe episodic pain that occurs in the area innervated by the trigeminal nerve, the face, and jaw. Improvement consists of a decrease in the frequency and severity of pain. The corneal or blink reflex is a normal finding and usually is not affected by trigeminal neuralgia. The ability to close both eyes involves the motor function of the facial (seventh) cranial nerve.

A patient has been admitted with a C5-level spinal cord injury and has marked hypotension. What pharmacologic therapies would the nurse expect to be prescribed for this patient? Select all that apply. Nitrates Diuretics Beta blockers Anticoagulants Intravenous fluids

D, E The spinal cord injury at the C5 level causes loss of sympathetic nervous system tone in peripheral vessels. This results in chronic low blood pressure with potential postural hypotension. Lack of muscle tone to aid venous return can result in sluggish blood flow, thus predisposing the patient to deep vein thrombosis. To treat hypotension, a vasopressor agent such as dopamine or norepinephrine should be administered. Fluid replacement also helps in maintaining optimal blood pressure. Nitrates are potent vasodilators and would worsen the hypotension if administered. Diuretics increase fluid loss from the body and may worsen hypotension. Beta blockers decrease the heart rate and cardiac output, which lower blood pressure and make the heart beat more slowly and with less force; this is inappropriate to treat hypotension.

A patient with trigeminal neuralgia is scheduled for microvascular decompression of the trigeminal nerve. What is appropriate for the nurse to teach the patient about the procedure? Select all that apply. "It may cause loss of sensation in the cornea." "It may cause some amount of numbness in your face." "It will involve injection of glycerol into the trigeminal nerve." "It will be performed by making a small hole behind your ear." "It is one of the safest surgical treatments for trigeminal neuralgia." "It involves displacement of the blood vessels pressing on the nerve."

D, F The nurse should explain to the patient that a small hole will be made in the skull behind the ear. This is called suboccipital craniotomy. Microvascular decompression involves displacement and repositioning of the blood vessels pressing on the patient's trigeminal nerve. It relieves pain without any sensory loss. Therefore there should be no loss of corneal sensation or numbness in the face. Microvascular decompression does not involve injection of glycerol. Glycerol rhizotomy involves injection of glycerol into the trigeminal cistern. Although there is no residual sensory loss with microvascular decompression, it is potentially dangerous because it involves an intracranial procedure.