Lewis Book/Evolve Questions: Ch. 60 and Giddens Concept 26

Which hormones are involved in building and maintaining healthy bone tissue? Select all that apply. A.Insulin B.Thyroxine C.Glucocorticoids D.Growth hormone E.Parathyroid hormone

A.Insulin D.Growth hormone Insulin works together with growth hormone to increase bone length, which helps to build and maintain healthy bone tissue. Thyroxine increases the rate of protein synthesis in all types of tissues. Glucocorticoids regulate protein metabolism to reduce or intensify the organic matrix of bone. Parathyroid hormone secretion stimulates bones to promote osteoclastic activity and release calcium into the blood when serum calcium levels are lowered.

The nurse encourages a ventilated client with advanced Guillain-Barré syndrome (GBS) to communicate by which simple technique? A.Blinking for "yes" or "no" B.Moving lips to speak C.Using sign language D.Using a laptop to write

Blinking for "yes" or "no" To communicate, a ventilated client with advanced GBS needs to blink for "yes" or "no." A simple technique involving eye blinking or moving a finger to indicate "yes" and "no" is the best way for the ventilated client with GBS to communicate.Moving the lips is difficult to do around an endotracheal tube and is exhausting for the client. Sign language is very time-consuming to learn, unless the client and family already know it. Use of a laptop may prove too challenging for the client in advanced stages of GBS.

During assessment of the patient with trigeminal neuralgia, what should you do (select all that apply)? A. Inspect all aspects of the mouth and teeth. B. Assess the gag reflex and respiratory rate and depth. C. Lightly palpate the affected side of the face for edema. D. Test for temperature and sensation perception on the face. E. Ask the patient to describe factors that initiate an episode.

A. Inspect all aspects of the mouth and teeth. D. Test for temperature and sensation perception on the face. E. Ask the patient to describe factors that initiate an episode. Assessment of the attacks, including the triggering factors, characteristics, frequency, and pain management techniques, helps you plan patient care. The painful episodes are usually initiated by a triggering mechanism of light cutaneous stimulation at a specific point (trigger zone) along the distribution of the nerve branches. Precipitating stimuli include chewing, tooth brushing, a hot or cold blast of air on the face, washing the face, yawning, and talking. Touch and tickle seem to predominate as causative triggers, rather than pain or changes in temperature.

The nurse is teaching a client about the risk factors of restless legs syndrome. Which statement by the client indicates a correct understanding of the nurse's instruction? A."Cigarettes and alcohol must be avoided." B."I need to exercise my legs before bedtime." C."It is important to stay off my feet." D."Over-the-counter drugs must not be taken."

A."Cigarettes and alcohol must be avoided." The correct statement about the risks of restless legs syndrome is cigarettes and alcohol must be avoided. Clients with restless legs syndrome need to avoid as many risk factors as possible or make lifestyle modifications. Examples include avoiding caffeine and alcohol, quitting smoking, and losing weight.Clients with RLS need to be encouraged to exercise but not engage in strenuous activity within 2-3 hours before bedtime. Use of over-the-counter drugs is not contraindicated for clients with restless legs syndrome.

A client's spouse expresses concern that the client, who has Guillain-Barré syndrome (GBS), is becoming very depressed and will not leave the house. What is the nurse's best response? A."Contact the Guillain-Barré Syndrome Foundation International for resources. Here is their contact information." B."Try inviting several people over so the client won't have to go out." C."Let your spouse stay alone. Your spouse will get used to it." D."This behavior is normal."

A."Contact the Guillain-Barré Syndrome Foundation International for resources. Here is their contact information." The nurse's best response to a client's spouse about the client with GBS being depressed is referring the client to the GBS Foundation for resources. The Guillain-Barré Syndrome Foundation International (www.gbs-cidp.org) provides resources and information for clients and their families. The Foundation may be able to help the spouse and family find local support groups to assist the family with the transition.Inviting one close friend over is appropriate, but more than one might overwhelm the client. Telling the spouse to let the client say alone and that the behavior is normal is not helpful and inappropriate. Although depression is expected initially, some action does need to be taken to prevent further deterioration.

A patient learns about rehabilitation for a spinal cord tumor. Which statement by the patient reflects appropriate understanding of this process? A."With rehabilitation, I will be able to function at my highest level of wellness." B."I want to be rehabilitated for my daughter's wedding in 2 weeks." C."Rehabilitation will be more work done by me alone to try to get better." D."I will be able to do all my normal activities after I go through rehabilitation."

A."With rehabilitation, I will be able to function at my highest level of wellness." Rehabilitation is an interprofessional endeavor to teach and enable the patient to function at his or her highest level of wellness and adjustment. Intense work will be required of all involved persons; the process will take longer than 2 weeks. With neurologic dysfunction, the patient will not be able to perform all normal activities at the same level as previously.

The patient with peripheral facial paresis on the left side is diagnosed with Bell's palsy. What should the nurse teach regarding self-care (select all that apply.)? Select all that apply. A.A facial sling to support the muscles and facilitate eating B.Dark glasses and artificial tears to protect the eyes C.Administration of corticosteroid medications D.Administration of antiseizure medications E.Surgery if conservative therapy is not effective F.Preparing for a nerve block to manage pain

A.A facial sling to support the muscles and facilitate eating B.Dark glasses and artificial tears to protect the eyes C.Administration of corticosteroid medications Self-care for Bell's palsy includes use of corticosteroid medications to decrease inflammation of the facial nerve (cranial nerve VII). Dark glasses and artificial tears protect the cornea from drying because of the inability to close the eyelid. A facial sling may be fitted by the occupational therapist to support muscles and facilitate eating. Antiseizure medications, a nerve block, or surgeries are used for trigeminal neuralgia.

A client with osteomyelitis has a slow rate of healing. Which factors can contribute to reduced healing in the client? Select All that apply A.Diabetes B.Cataract C.Smoking D.Dermatitis E.Alcoholism

A.Diabetes C.Smoking E.Alcoholism Diabetes causes narrowing of blood vessels, thereby causing diminished blood supply to the affected organ or tissue; clients with diabetes have a slow healing rate. Intake of tobacco through smoking may reduce the blood supply to the affected area, thereby slowing down the healing process. Alcohol abuse reduces the amount of nutrients and vitamins required for muscle growth, thereby affecting the healing process. Cataract is a disease of the eye and does not affect the musculoskeletal system. Similarly, dermatitis is a skin condition that does not affect the musculoskeletal system.

A nurse observes a patient walking in the hall. Which assessment is the nurse able to complete? A.Gait and balance B.Speech and hearing C.Mental alertness D.Ability to follow directions

A.Gait and balance When the patient is walking, the nurse is assessing for gait and balance (mobility). Speech, hearing, mental alertness, and the ability to follow directions do not have a bearing on mobility.

Patients who are experiencing immobility often have which of the following emotions? Select all that apply. A.Helplessness B.Hunger C.Anger D.Anxiety E.Increased communication F.Improved self-worth

A.Helplessness C.Anger D.Anxiety Patients who experience immobility often have psychological issues such as helplessness, anger, and anxiety. Hunger, increased communication, and improved self-worth are usually the opposite of what is experienced.

A 68-yr-old 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 caregiver to assist with bowel evacuation (select all that apply.)? Select all that apply. A.Limit caffeinated beverages. B.Establish bowel evacuation time at bedtime. C.Drink 1800 to 2800 mL of water or juice. D.Eat 20-30 g of fiber per day. E.Use oral laxatives every day. F.Drink more milk.

A.Limit caffeinated beverages. C.Drink 1800 to 2800 mL of water or juice. D.Eat 20-30 g of fiber per day. 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. Caffeine stimulates fluid loss and can contribute to constipation, so caffeine intake should be limited. Milk also may cause constipation. Daily oral laxatives may cause diarrhea and are avoided unless needed. 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 primary healthcare provider schedules a bone scan for a client with osteoporosis. Which nursing actions are beneficial for the client? Select all that apply. A.Placing the client in the supine position B.Verifying if the client has a shellfish allergy C.Ensuring that the client has no metal on the clothing D.Instructing the client to empty the bladder before the scan E.Informing the client that the post-procedure headache resolves in 2 days

A.Placing the client in the supine position D.Instructing the client to empty the bladder before the scan A bone scan is done to assess osteomyelitis, osteoporosis, primary and metastatic malignant lesions of bone, and certain fractures. The nurse has to place that client in the supine position for one hour for easy assessment while performing the bone scan. The nurse should instruct the client to empty the bladder before scanning. The client undergoing a computed tomography (CT) scan must be screened for a shellfish allergy to reduce the incidences of anaphylactic shock associated with the radiocontrast agent. Radio waves and a magnetic field are used during magnetic resonance imaging (MRI); therefore, the nurse should ensure that the client has no metal on the clothing before the procedure. The main risk of a myelogram is a spinal headache that usually resolves within 2 days of the procedure. Next

The nurse is caring for a patient admitted with a spinal cord injury after 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? A.Spinal shock syndrome B.Anterior cord syndrome C.Brown-Séquard syndrome D.Central cord syndrome

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

A client has a total hip arthroplasty. What should the nurse do when caring for this client after surgery? A.Use a pillow to keep the legs abducted. B.Elevate the client's affected limb on a pillow. C.Turn the client using the log-rolling technique. D.Place a trochanter roll along the entire extremity.

A.Use a pillow to keep the legs abducted. Using a pillow to keep the legs abducted ensures abduction of the leg to maintain position of the prosthesis and prevent dislocation. Elevating the client's affected limb on a pillow is not necessary as long as abduction of the limb is maintained. Turning the client using the log-rolling technique causes flexion of the hip; it is done only if prescribed by the primary healthcare provider. A trochanter roll at the ankle can cause damage to the peroneal nerve along the external malleolus.

A patient is just admitted to the hospital following a spinal cord injury at the level of T4. A priority of nursing care for the patient is monitoring for A.return of reflexes. B.bradycardia with hypoxemia. C.effects of sensory deprivation. D.fluctuations in body temperature.

B.bradycardia with hypoxemia

A young adult is hospitalized after an accident that resulted in a complete transection of the spinal cord at the level of C7. The nurse informs the patient that after rehabilitation, the level of function that is most likely to occur is the ability to A.breathe with respiratory support. B.drive a vehicle with hand controls. C.ambulate with long-leg braces and crutches. D.use a powered device to handle eating utensils.

B.drive a vehicle with hand controls.

The nurse is reviewing skin care of an immobilized patient with an unlicensed assistive employee. The nurse knows the employee understands the importance of skin care when making which statement? A."Proper care of the skin is important because the immobilized patient does not want to smell bad." B."Proper care of the skin is important because the immobilized patient is at high risk for breakdown." C."Proper care of the skin is important because the immobilized patient will have many visitors." D."Proper care of the skin is important because the immobilized patient will be incontinent."

B."Proper care of the skin is important because the immobilized patient is at high risk for breakdown." Skin care is important for an immobilized patient because the patient is prone to skin breakdown from pressure and body fluids. Body odor (smell) is embarrassing to the patient, but it does not pose a risk to the skin. Not every immobilized patient is incontinent. Having visitors does not pose a risk to the skin.

A 22-yr-old woman with paraplegia after a spinal cord injury tells the home care nurse she experiences bowel incontinence two or three times each day. Which action by the nurse is most appropriate? A.Instruct the patient to avoid all caffeinated and carbonated beverages. B.Assess bowel movements for frequency, consistency, and volume. C.Insert a rectal stimulant suppository. D.Teach the patient to gradually increase intake of high-fiber foods.

B.Assess bowel movements for frequency, consistency, and volume. The nurse should establish baseline bowel function and explore the patient's current knowledge of an appropriate bowel management program after spinal cord injury. To prevent constipation, caffeine intake should be limited but need not be eliminated. After stabilization, creation of a bowel program including a rectal stimulant, digital stimulation, or manual evacuation at the same time each day will regulate bowel elimination. Instruction on high-fiber foods is indicated if the patient has a knowledge deficit.

While on a mission trip, the nurse is caring for a patient diagnosed with tetanus. The patient has been given tetanus immune globulin (TIG). What interprofessional care is appropriate (select all that apply.)? Select all that apply. A.Teach correct processing of canned foods. B.Control spasms with diazepam (Valium). C.Provide analgesia with opioids (morphine). D.Administer penicillin. E.Administer polyvalent antitoxin. F.Prepare for tracheostomy for mechanical ventilation.

B.Control spasms with diazepam (Valium). C.Provide analgesia with opioids (morphine). D.Administer penicillin. F.Prepare for tracheostomy for mechanical ventilation. Penicillin is administered to inhibit further growth of Clostridium tetani. Control of the spasms of tetanus is essential because laryngeal and respiratory spasms cause apnea and anoxia. Morphine can be used to manage pain. A tracheostomy is performed early so mechanical ventilation may be done to maintain respirations. Using polyvalent antitoxin and teaching the correct canning process are done for botulism.

Which intervention should the nurse perform first in the acute care of a patient with autonomic dysreflexia? A.Check for bowel impaction B.Elevate the head of the bed C.Administer intravenous hydralazine D.Urinary catheterization

B.Elevate the head of the bed Positioning the patient upright is the first action so blood pressure will decrease. Then assessment of indwelling urinary catheter patency or immediate catheterization should be performed to relieve bladder distention. Next, the rectum should be examined for retained stool or impaction. Finally, the nurse will consider administering an intravenous antihypertensive medication if needed.

A 25-yr-old male patient who is a professional motocross racer has anterior spinal cord syndrome at T10. His history is significant for tobacco, alcohol, and marijuana use. What is the nurse's prioritywhen planning for rehabilitation? A.Prevent urinary tract infection. B.Encourage him to verbalize his feelings. C.Monitor the patient every 15 minutes. D.Teach him about using the gastrocolic reflex.

B.Encourage him to verbalize his feelings. To help the patient with coping and prevent self-harm, the nurse should create a therapeutic patient environment that encourages self-expression and verbalization of thoughts and feelings. The patient is at high risk for depression and self-injury because loss of function below the umbilicus is expected. He is a young adult male patient who will likely need a wheelchair and have impaired sexual function. Resuming a racing career is unlikely. Because the patient uses tobacco, alcohol, and marijuana frequently, hospitalization is likely to result in a loss of these habits and can make coping difficult. Preventing urinary tract infection and facilitating bowel evacuation with the gastrocolic reflex will be important during recovery. In rehabilitation, monitoring every 15 minutes is not needed unless the patient is on suicide precautions.

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

B.Help the client sit up. The nurse's first action for a T6 spinal cord injury client suddenly developing facial flushing and severe headache is to help the client sit up. The client is experiencing autonomic dysreflexia, which can produce severe and rapidly occurring hypertension. Getting the client to sit upright is the easiest and quickest action to take and has the most immediate chance of lowering blood pressure to the brain.Checking for fecal impaction, inserting a straight catheter, and loosening the clothing are important but will not immediately reduce blood pressure.

When planning care for a patient with a cervical spinal cord injury (C5), which nursing diagnosis has the highest priority? A.Disabled family coping related to the extent of trauma B.Ineffective airway clearance related to cervical spinal cord injury C.Risk for impaired tissue integrity related to paralysis D.Impaired urinary elimination related to tetraplegia

B.Ineffective airway clearance related to cervical spinal cord injury Maintaining a patent airway is the most important goal for a patient with a cervical spinal cord injury. Although all are appropriate nursing diagnoses for a patient with a cervical spinal cord injury, respiratory needs are always the highest priority (ABCs).

During infancy, childhood, and adolescence, which nutrients are critical for the musculoskeletal development? A.Vitamins and minerals B.Protein and calcium C.Fats and carbohydrates D.Zinc and potassium

B.Protein and calcium Adequate stores of protein and calcium allow the developing musculoskeletal system to grow properly. Without the proper vitamins, minerals, and protein, the bones would not develop as they should.

The nurse performs discharge teaching for a 34-yr-old male patient with a thoracic spinal cord injury (T2) from a construction accident. Which patient statement indicates teaching about autonomic dysreflexia is successful? A."A reflex erection may cause an unsafe drop in blood pressure." B."If I develop a severe headache, I will lie down for 15 to 20 minutes." C."I will perform self-catheterization at least six times per day." D."I can avoid this problem by taking medications to prevent leg spasms."

C."I will perform self-catheterization at least six times per day." Autonomic dysreflexia usually is caused by a distended bladder. Performing self-catheterization five or six times a day prevents bladder distention. Signs and symptoms of autonomic dysreflexia include a severe headache, hypertension, bradycardia, flushing, piloerection (goosebumps), and nasal congestion. Patients should raise the head of the bed to 45 to 90 degrees. This action helps to relieve hypertension (systolic pressure up to 300 mm Hg) that occurs with autonomic dysreflexia.

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

C."Keep straws available for drinking fluids." The instructions the nurse include for a client with a halo device is to keep straws available for drinking fluids. The halo device makes it difficult to bring a cup or a glass to the mouth.The head would be supported with a small pillow when sleeping to prevent unnecessary pressure and discomfort. Driving must be avoided because vision is impaired with the device. Swimming must be avoided to prevent the risk for infection.

A 52-year-old client reports fatigue and reduced strength in the limbs. Which suggestion given to the client will be most beneficial? A."Include protein-rich food in your diet." B."Drink two cups of skim milk each day." C."Perform push-ups in the morning." D."Give warm compresses to the limbs."

C."Perform push-ups in the morning." Decreased muscle strength (deconditioning) occurs with age and can be reduced by performing isometric exercises; therefore, suggesting that the client perform push-ups in the morning would be most beneficial. Proteins provide energy and promote healing and milk is rich in calcium and is good for overall health (especially bones), but neither of these will reduce fatigue or increase limb strength like exercise can. Warm compresses can reduce pain and inflammation caused by an injury but they will not reduce fatigue or increase limb strength.

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

C.Bradycardia Neurogenic shock is caused by the loss of vasomotor tone after injury and is characterized by bradycardia and hypotension. Loss of sympathetic innervation causes peripheral vasodilation, venous pooling, and decreased cardiac output. Thus hypertension, neurogenic spasticity, and bounding pedal pulses are not seen in neurogenic shock.

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

C.Fat embolism syndrome The nurse is concerned that fat embolism syndrome has occurred. Fat embolism syndrome (FES) is characterized by chest pain, dyspnea, anxiety, and mental status changes. Petechiae may develop around the neck, over the upper chest, buccal mucosa, and conjunctiva. This is an emergency. The nurse must notify the primary health care provider immediately.Autonomic dysreflexia is not associated with lumbar laminectomies. It is seen in spinal cord injuries. A cerebrospinal fluid (CSF) leak is a concern with laminectomy but would not present with these symptoms. Paralytic ileus may occur but is associated with abdominal pain and distention.

A child must experience mobility so he or she can explore and learn about the world. Lack of mobility in a child may interfere with which developmental milestone? A.Physiological bonding and growth B.Speech and hearing development C.Intellectual and psychomotor function D.Childhood play interaction

C.Intellectual and psychomotor function Immobility can cause intellectual and psychomotor deficits because children need to experience mobility to explore the world. Immobility does not have a direct effect on growth, speech, hearing, or play.

The nurse is caring for a patient with a halo vest after cervical spine injury. Which care instructions should the nurse include in the patient's discharge plan? A.Clean around the pins using betadine swab sticks. B.Use the frame and vest to assist in positioning. C.Keep a wrench close or attached to the vest. D.Loosen both sides of the vest to provide skin care.

C.Keep a wrench close or attached to the vest. A halo vest is used to provide cervical spine immobilization while vertebrae heal. A wrench should accompany the halo vest at all times in case emergency removal of the vest is needed (e.g., performance of CPR). Cleaning around the pins is typically performed with half strength hydrogen peroxide, normal saline, or chlorhexidine, based on provider instructions. Only one side of the vest can be loosened for skin care and changing clothes. After that side has been reattached, the other side of the vest can be loosened.

A client is being discharged with paraplegia secondary to a motor vehicle crash and expresses concern over the ability to cope in the home setting after the injury. Which is the best resource for the nurse to provide for the client? A.Hospital library B.Internet C.National Spinal Cord Injury Association D.Provider's office

C.National Spinal Cord Injury Association The best resource for the nurse to provide is the National Spinal Cord Injury Association. The National Spinal Cord Injury Association will inform the client of support groups in the area and will assist in answering questions regarding adjustment in the home setting.The hospital library is not typically consumer-oriented. Most information available in the library is targeted to health care professionals. The Internet is not the best resource simply because of the unlimited volume of information available and its questionable quality. Although the provider's office may have information, the information may not be as comprehensive and current as other options.

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

C.Nifedipine (Procardia) The nurse anticipates that the primary health care provider will prescribe nifedipine for a spinal cord injury client who has an elevated blood pressure and severe headache. This client is experiencing autonomic dysreflexia (AD). Nifedipine (Procardia), a calcium channel blocker, can be administered to treat AD and lower blood pressure. If AD is not treated, a hemorrhagic stroke can occur.Dopamine hydrochloride (Inotropin) is an inotropic agent used to treat severe hypotension. Methylprednisolone (Solu-Medrol) is a glucocorticoid and is not indicated because it may further increase blood pressure. Ziconotide (Prialt) is an N-type calcium channel blocker on those nerves that usually transmit pain signals to the brain.

The nurse is caring for a client with a distal femoral shaft fracture. For which clinical indicator unique to a fat embolus should the nurse assess the client? A.Oliguria B.Dyspnea C.Petechiae D.Confusion

C.Petechiae At the time of fracture or orthopedic surgery, fat globules may move from bone marrow into the bloodstream; also, increased catecholamines cause mobilization of fatty acids and the development of fat globules. In addition to obstructing vessels in the lung, brain, and kidneys with systemic embolization from fat globules, petechiae are noted in buccal membranes, conjunctival sacs, hard palate, chest, and anterior axillary folds; these indicators occur only with fat embolism. Oliguria is a clinical finding of an embolus but is not specific to a fat embolus. Dyspnea is not a clinical manifestation of a fat embolus, but an embolus. Confusion is a clinical manifestation of an embolus but is not specific to a fat embolus.

A client is admitted with an exacerbation of Guillain-Barré syndrome (GBS), presenting with dyspnea. Which intervention does the nurse perform first? A.Calls the Rapid Response Team (RRT) to intubate B.Instructs the client on how to cough effectively C.Raises the head of the bed to 45 degrees D.Suctions the client

C.Raises the head of the bed to 45 degrees The nurse's first action for a client with an exacerbation of GBS who now has dyspnea is to raise the head of the bed to 45 degrees. The head of the client's bed must be elevated to allow for increased lung expansion. This action helps improve the client's ability to breathe.Calling the RRT for intubation may be necessary if dyspnea is severe or oxygen saturation does not respond to oxygen therapy. Close monitoring of respiratory status is indicated because of the acute stages of GBS. Instructing the client on how to cough effectively is not the priority in this case. The client would be suctioned as needed but cautiously to avoid vagal stimulation.

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

C.Regular turning and repositioning Regular turning and repositioning are the best way to prevent complications of immobility in clients with spinal cord problems.A registered dietitian may be consulted to encourage nutrition to optimize diet for general health and to reduce osteoporosis. Frequent ambulation may not be possible for these clients. Use of special pressure-relief devices is important but is not the best way to prevent immobility complications.

The nurse is providing care for a patient diagnosed with Guillain-Barré syndrome. Which assessment should be the nurse's priority? A.Musculoskeletal assessment B.Pain assessment C.Respiratory assessment D.Glasgow Coma Scale

C.Respiratory assessment Although all the assessments are necessary in the care of patients with Guillain-Barré syndrome, the acute risk of respiratory failure requires vigilant monitoring of the patient's respiratory function.

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

C.The client's chest moves very little with each respiration. The most rapid action is needed for a spinal cord injury client injured one hour prior to arrival whose chest moves very little with each respiration. Airway and breathing are always of major concern in a spinal cord injury, especially in an injury near C3 to C5, where the spinal nerves control the diaphragm.Bradycardia and hypotension are indications neurogenic shock due to disruption of autonomic pathways. This will need to be addressed rapidly however airway and breathing are always the top priority. Flaccid paralysis below the level of the injury is to be expected.

During rehab, a patient with spinal cord injury begins to ambulate with long leg braces, which level of injury does the nurse associate with this degree of recovery? a. L1-2 b. T6-7 c. T1-2 d. C7-8

Correct answer: a During rehabilitation, the patient with SCI at L1-2 is able to maintain good sitting balance and full use of a wheelchair. The patient ambulates with long leg braces. Patients with higher level injury are unable to attain this degree of ambulation.

For a 65 y/o woman who has lived with a T1 spinal cord injury for 20 years, which health teaching instructions should the nurse emphasize? a. a mammogram is needed every year b. bladder function tends to improve with age c. heart disease is not common in people with spinal cord injury d. as a person ages, the need to change body position is less important

Correct answer: a Rationale: Health promotion and screening are important for an older patient with a spinal cord injury. Older adult women with spinal cord injuries should perform monthly breast examinations and undergo yearly mammography.

A patient with a T4 spinal cord injury experiences neurogenic shock as a result of sympathetic NS dysfunction. what would the nurse recognize as characteristic of this condition? a. tachycardia b. hypotension c. increase cardiac output d. peripheral vasoconstriction

Correct answer: b Rationale: Neurogenic shock results from loss of vasomotor tone caused by injury and is characterized by hypotension and bradycardia. Loss of sympathetic nervous system innervation causes peripheral vasodilation, venous pooling, and a decrease in cardiac output. These effects are usually associated with a cervical or high thoracic injury (T6 or higher).

The most common early symptom of a spinal cord tumor is a. urinary incontinence b. back pain that worsens with activity c. paralysis below the level of involvement d. impaired sensation of pain, temp, and light touch

Correct answer: b Rationale: The most common early symptom of a spinal cord tumor is pain in the back, with radicular pain following the nerve(s) affected. The location of the pain depends on the level of compression. The pain worsens with activity, coughing, straining, and lying down.

A patient with a C7 spinal cord injury undergoing rehab tells the nurse he must have the flu because he has a bad headache and nausea, the nurse's first priority is to: a. call the HCP b. check the patient's temp c. check the patient's BP d. elevate the HOB to 90 degrees

Correct answer: c Rationale: Autonomic hyperreflexia is a massive, uncompensated cardiovascular reaction mediated by the sympathetic nervous system. Manifestations include hypertension (up to 300 mm Hg systolic), throbbing headache, marked diaphoresis above the level of the injury, bradycardia (30 to 40 beats/min), piloerection, flushing of the skin above the level of the injury, blurred vision or spots in the visual fields, nasal congestion, anxiety, and nausea. It is important to measure BP when a patient with a spinal cord injury complains of headache. Other nursing interventions in this serious emergency are elevation of the head of the bed 45 degrees or sitting the patient upright, notification of the physician, and assessment to determine the cause. Table 60-8 lists the causes and symptoms of autonomic hyperreflexia. The nurse must monitor BP frequently during the episode. An α-adrenergic blocker or an arteriolar vasodilator may be administered.

A patient with spinal cord injury is experiencing severe neurologic deficits, what is the most likely mechanism of injury for this patient? a. compression b. hyperextension c. flexion rotation d. extension rotation

Correct answer: c Rationale: The major mechanisms of SCI are flexion, hyperextension, flexion-rotation, extension-rotation, and compression. The flexion-rotation injury is the most unstable because spinal ligaments are torn. This injury most often contributes to severe neurologic deficits.

During routine assessment of a patient with Guillain-Barré syndrome, you find the patient is short of breath. What is causing the patient's respiratory distress? A. Elevated protein levels in the cerebrospinal fluid (CSF) B. Immobility resulting from ascending paralysis C. Degeneration of motor neurons in the brainstem and spinal cord D. Paralysis ascending to the nerves that stimulate the thoracic area

D. Paralysis ascending to the nerves that stimulate the thoracic area Guillain-Barré syndrome is characterized by ascending, symmetric paralysis that usually affects cranial nerves and the peripheral nervous system. The most serious complication of this syndrome is respiratory failure, which occurs as the paralysis progresses to the nerves that innervate the thoracic area.

The nurse is caring for a 63-yr-old woman taking prednisone (Deltasone) for Bell's palsy. Which statement by the patient requires correction by the nurse? A."I can take acetaminophen with the prescribed medications." B."Chances of a full recovery are good if I take the medication" C."I can take the medication with food or milk." D."The medication should be started 1 week after paralysis."

D."The medication should be started 1 week after paralysis." Prednisone should be started immediately. Patients have the best chance for full recovery if prednisone is initiated before complete paralysis occurs. Prednisone will be tapered over the last 2 weeks of treatment. Oral prednisone may be taken with food or milk to decrease gastrointestinal upset. Patients with Bell's palsy usually begin recovery in 2 to 3 weeks, and most patients have complete recovery in 3 to 6 months. No serious drug interactions occur between prednisone and acetaminophen.

Which manifestations in a patient with a thoracic spinal cord injury (T4) should alert the nurse to possible autonomic dysreflexia? A.Decreased level of consciousness or hallucinations B.Irregular respirations and shortness of breath C.Abdominal distention and absence of bowel sounds D.Headache and rising blood pressure

D.Headache and rising blood pressure Manifestations of autonomic dysreflexia are hypertension (up to 300 mm Hg systolic), a throbbing headache, bradycardia, and diaphoresis. Respiratory changes, decreased level of consciousness, and gastrointestinal complaints are not characteristic manifestations.

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

D.Log rolling the client Log rolling the client who has undergone spinal surgery is the best way to keep the spine in alignment. The client who has undergone spinal surgery must remain straight and turned as a unit.The Trendelenburg position is not indicated for the client who has undergone spinal surgery, nor should the client be lifted or encouraged to get up in a chair.

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

D.Patent airway The nursing priority when assessing a client with a spinal cord injury is a patent airway. Clients with injuries at or above T6 are at risk for respiratory complications. Assessing for a patent airway is essential.Asking the client about current medications and allergies is part of every trauma assessment. Assessing the level of consciousness utilizing the Glasgow Coma Score (GCS) is an important part of the trauma assessment. Determining the level of loss of sensation will be included in the neurological evaluation.

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

D.Positioning the client to maximize ventilation potential The priority nursing intervention for a client with a spinal cord injury at the seventh cervical vertebra is to position the client to maximize ventilation potential. Airway management is the priority for the client with a spinal cord injury. The client with a cervical spinal cord injury is at high risk for respiratory compromise because the cervical spinal nerves (C3-C5) innervate the phrenic nerve, controlling the diaphragm.Auscultating bowel sounds is important since paralytic ileus can develop from a SCI; however this is not the priority intervention. Beginning bladder retraining and monitoring the nutritional status will be important for adequate healing and progress to rehabilitation. However, these interventions can be delayed until major life threats are addressed.