Chapter 60

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?

Aspiration of food into the airways

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.

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.

Atropine Vasopressor drugs

The nurse expects a prescription for what treatment to help control a patient's spasms that are caused by tetanus?

Barbiturates

A nurse is planning a bowel program for a patient with a T7 level spinal cord injury. What is the most suitable position for bowel evacuation for this patient?

Sitting Position

Which discharge instruction should the nurse provide to a patient with trigeminal neuralgia?

"Eat a diet that is high in protein."

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?

"With rehabilitation, I will be able to function at my highest level of wellness."

In which order does Guillain-Barre syndrome (GBS) develop and resolve?

1.The myelin layer of the affected nerves is lost. 2.The transmission of nerve impulses is slowed or stopped. 3.The muscle innervated by the damaged nerve undergoes denervation and atrophy. 4.The nerve undergoes slow re-myelination. 5.The neurologic function returns in a proximal-to-distal pattern.

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

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.

3. There is loss of nervous control of the blood vessels. 4. The amount of blood pumped out of the heart reduces. 5. There is pooling of blood in the veins of the extremities.

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 virus causes inflammation, which leads to paralysis of the facial nerve.

The nurse is caring for a patient with poikilothermia. What condition in the patient's medical record likely caused this clinical manifestation?

Spinal cord injury

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?

Applying a rigid cervical collar and using a backboard to transport the patient.

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 drive an electric wheelchair

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

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 Hypotonicity of the lower Limbs

Which clinical manifestation would the nurse interpret as a manifestation of neurogenic shock in a patient with acute spinal cord injury?

Bradycardia

A patient with a T-4 injury develops signs of neurogenic shock. Which assessment findings are expected with this complication? Select all that apply.

Bradycardia Hypotension Peripheral vasodilation

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?

Brown-Séquard syndrome

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

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?

Carbamazepine

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 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).

The nurse is providing care to a patient with a spinal cord injury who has areflexic bladder. Which syndrome does the nurse anticipate?

Conus medullaris syndrome

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

A patient presents with initial manifestations of tetanus. The nurse expects what assessment finding?

Stiffness in the jaw

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.

What type of blunt trauma can lead to a spinal cord injury?

Diving accident

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.

Ensure that the patient's body is correctly aligned. Use a sternal-occipital-mandibular immobilizer brace. Use a firm backboard to prevent any spinal movement.

The nurse is performing a musculoskeletal assessment on the older patient. Which is the most important factor considered by the nurse when performing the musculoskeletal assessment on the older patient?

Exercise practices

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?

Facial Flushing

When planning care for a patient with a C5 spinal cord injury, which nursing diagnosis has the highest priority ?

Ineffective airway clearance caused by high cervical spinal cord injury

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 find the degree of spinal canal compromise.

Which diagnostic study is used to assess soft tissue injury and neurologic changes?

MRI

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.

PaCO 2= 55 mm Hg pH = 7.27

A patient with Guillain-Barré syndrome is admitted to the medical-surgical floor. What does the nurse understand regarding this disorder?

Patients also may have syndrome of inappropriate antidiuretic hormone (SIADH).

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.

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.

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?

Providing food through a nasogastric tube

The nurse reviews a patient's medical record and notes tic douloureux. The nurse expects what assessment finding?

Recurrent episodes of stabbing pain along the distribution of the trigeminal nerve

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

Respiratory Assessment

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.

Sudden onset of severe headache Sweating above the level of the SCI Flushed face and chest above the level of the SCI

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.

Tearing of the eye Pain on the side of the nose

The nurse is providing care to a patient with trismus. Which associated condition does the nurse suspect?

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.

There is excess gastric distention, and the stomach is hard. The sensation of a full bowel is not perceived by the patient, and fecal incontinence is present.

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 The muscle responsible for breathing is paralyzed. There is accumulation of secretions in the lungs, which has caused collapse of the lungs.

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.

Unable to whistle Flat nasolabial fold

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

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. Inspect all skin areas on a daily basis using a mirror as necessary.

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.

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

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?

Maintaining a patent airway

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.

Monitor blood pressure regularly. Notify the primary health care provider. Check for the presence of bowel impaction. Remove the kink in the catheter and drain the bladder.