Nursing 275 Exam 4 MS & Spinal Cord Injury

A nurse plans care for a client who is bedridden. Which assessment should the nurse complete to ensure to prevent pressure ulcer formation? a. Nutritional intake and serum albumin levels b. Pressure ulcer diameter and depth c. Wound drainage, including color, odor, and consistency d. Dressing site and antibiotic ointment application

A

A patient has purchased capsaicin over-the-counter cream to use for muscle aches and pains. What education is most important to give this patient? A. Apply with a gloved hand only to the site of pain. B. Apply the medication liberally above and below the site of pain. C. Apply to areas of redness and irritation only. D. Apply liberally with a bare hand to the affected limb.

A. Apply with a gloved hand only to the site of pain. Capsaicin should be applied to the site of pain with a gloved hand to avoid introducing the capsaicin to the eyes or other parts of the body not under treatment. Options 2, 3, and 4 are incorrect. Capsaicin should be applied only to the site of pain and never with the bare hand. It should not be applied to irritated or open skin areas and should be discontinued if irritation occurs.

Cyclobenzaprine (Amrix, Flexeril) is prescribed for a patient with muscle spasms of the lower back. Appropriate nursing interventions would include which of the following? (Select all that apply.) A. Assessing the heart rate for tachycardia B.Assessing the home environment for patient safety concerns C.Encouraging frequent ambulation D. Providing oral suction for excessive oral secretions E. Providing assistance with activities of daily living such as reading

A. Assessing the heart rate for tachycardia B.Assessing the home environment for patient safety concerns E. Providing assistance with activities of daily living such as reading Adverse reactions to cyclobenzaprine include drowsiness, dizziness, dry mouth, rash, blurred vision, and tachycardia. Because the medication can cause drowsiness and dizziness, ensuring patient safety must be a priority. The patient may need assistance with reading or other activities requiring visual acuity if blurred vision occurs. Options 3 and 4 are incorrect. Patients who are experiencing back pain often have orders for limited ambulation until muscle spasms have subsided.

A patient who has been prescribed baclofen (Lioresal) returns to the health care provider after a week of drug therapy, complaining of continued muscle spasms of the lower back. What further assessment data will the nurse gather? A. Whether the patient has been taking the medication consistently or only when the pain is severe B. Whether the patient has been consuming alcohol during this time C. Whether the patient has increased the dosage without consulting the health care provider D. Whether the patient's log of symptoms indicates that the patient is telling the truth

A. Whether the patient has been taking the medication consistently or only when the pain is severe Muscle relaxers such as baclofen (Lioresal) work best when taken consistently and not prn. Noting consistency of dosing helps to determine the appropriateness of dose, frequency, and drug effects. Options 2, 3, and 4 are incorrect. Consumption of alcohol or increasing the dose of muscle relaxers will increase the risk of sedation and drowsiness. The patient's log of symptoms and drug dose and frequency may assist the provider in determining the therapeutic outcome of the medication. The patient's report of pain or continued spasms should be considered an accurate account.

The nurse discusses the disease process of multiple sclerosis with the patient and caregiver. The patient will begin taking glatiramer (Copaxone), and then nurse is teaching the patient about the drug. Which of the following points should be include? 1. Drink extra fluids while this drug is given. 2. Local injection site irritation is a common effect. 3. Take the drug with plenty of water and remain in an upright position for at least 30 minutes. 4. The drug causes a loss of vitamin C so include extra citrus and foods containing vitamin C in the diet.

Answer: 2 Rationale: Glatiramer (Copaxone) is given by injection and often causes injection site irritation. Options 1, 3, and 4 are incorrect. Extra fluids do not need to be included and the drug is not given orally. It does not deplete vitamin C from the body.

. A nurse teaches a client who has a flaccid bladder. Which bladder training technique should the nurse teach? a. Stroking the medial aspect of the thigh b. Valsalva maneuver c. Self-catheterization d. Frequent toileting

B

A nurse cares for a client with decreased mobility. Which intervention should the nurse implement to decrease this client's risk of fracture? a. Apply shoes to improve foot support. b. Perform weight-bearing activities. c. Increase calcium-rich foods in the diet. d. Use pressure-relieving devices.

B

A rehabilitation nurse cares for a client who has generalized weakness and needs assistance with activities of daily living. Which exercise should the nurse implement? a. Passive range of motion b. Active range of motion c. Resistive range of motion d. Aerobic exercise

B

A rehabilitation nurse cares for a client who is wheelchair bound. Which intervention should the nurse implement to prevent skin breakdown? a. Place pillows under the client's heels. b. Have the client do wheelchair push-ups. c. Perform wound care as prescribed. d. Massage the client's calves and feet with lotion.

B

The patient is scheduled to receive rimabotulinumtoxinB (Myobloc) for treatment of muscle spasticity. Which of the following will the nurse teach the patient to report immediately? A.Fever, aches, or chills B. Difficulty swallowing, ptosis, blurred vision C. Continuous spasms and pain on the affected side D. Moderate levels of muscle weakness on the affected side

B. Difficulty swallowing, ptosis, blurred vision Dysphagia, ptosis, and blurred vision are all symptoms of possible botulinum toxin B toxicity and must be reported immediately. Options 1, 3, and 4 are incorrect. Fever, aches, and chills are not anticipated side effects. Moderate levels of muscle weakness may occur after the drug is administered, and strengthening exercises may be needed on the affected side. Continuous muscle spasms and pain should not occur because the drug blocks muscle contraction.

A female patient is prescribed dantrolene (Dantrium) for painful muscle spasms associated with multiple sclerosis. The nurse is writing the discharge plan for the patient and will include which of the following teaching points? (Select all that apply.) A. If muscle spasms are severe, supplement the medication with hot baths or showers three times per day. B. Inform the health care provider if she is taking estrogen products. C. Sip water, ice, or hard candy to relieve dry mouth. D. Return periodically for required laboratory work. E. Obtain at least 20 minutes of sun exposure per day to boost vitamin D levels.

B. Inform the health care provider if she is taking estrogen products. C. Sip water, ice, or hard candy to relieve dry mouth. D. Return periodically for required laboratory work. Dantrolene (Dantrium) may cause hepatotoxicity with the greatest risk occurring for women over age 35, and periodic laboratory tests will be required for monitoring. Estrogen taken concurrently with dantrolene may increase this risk. The drug may cause dry mouth and sucking on hard candy, sucking ice chips, or sipping water may help relieve the dryness. Options 1 and 5 are incorrect. Dantrolene may cause erratic blood pressure, including hypotension, and hot baths or showers cause vasodilation, increasing the risk for syncope and falls. The drug may cause photosensitivity and direct exposure to the sun should be avoided.

A nurse is caring for a client who has a spinal cord injury at level T3. Which intervention should the nurse implement to assist with bladder dysfunction? a. Insert an indwelling urinary catheter. b. Stroke the medial aspect of the thigh. c. Use the Credé maneuver every 3 hours. d. Apply a Texas catheter with a leg bag.

C

A patient has been prescribed clonazepam (Klonopin) for muscle spasms and stiffness secondary to an automobile accident. While the patient is taking this drug, what is the nurse's primary concern? A. Monitoring hepatic laboratory work B. Encouraging fluid intake to prevent dehydration C. Assessing for drowsiness and implementing safety measures D. Providing social services referral for patient concerns about the cost of the drug

C. Assessing for drowsiness and implementing safety measures Clonazepam (Klonopin) is a benzodiazepine; because it works on the C N S, it may cause significant drowsiness and dizziness. Safety measures should be implemented to prevent falls and injury. Options 1, 2, and 4 are incorrect. Benzodiazepines may cause hepatotoxicity in patients with existing hepatic insufficiency and may be needed for long-term monitoring. This drug was prescribed after a health care provider's assessment and is currently given to treat a potential short-term condition. The drug should not cause dehydration and is available in generic form. If cost is a concern, social service aid may be needed, but the primary concern for the nurse is safety.

A nurse teaches a client about performing intermittent self-catheterization. The client states, "I am not sure if I will be able to afford these catheters." How should the nurse respond? a. "I will try to find out whether you qualify for money to purchase these necessary supplies." b. "Even though it is expensive, the cost of taking care of urinary tract infections would be even higher." c. "Instead of purchasing new catheters, you can boil the catheters and reuse them up to 10 times each." d. "You can reuse the catheters at home. Clean technique, rather than sterile technique, is acceptable."

D

The nurse reviews the discharge and home care instructions with a pt who had conventional open back surgery. Which statement by the patient indicates further teaching is needed? a. "I will drive myself to the doctor's office next week." b. "I guess my wife will have to walk to dog for 6 more weeks." c. "I will try to increase fruits and vegetables and decrease fats." d. "I plan to get a new ergonomic chair at work."

a. "I will drive myself to the doctor's office next week."

Which disorder could have similar clinical presentation to multiple sclerosis? a. Amyotrophic lateral sclerosis b. Spinal cord tumor c. Guillan-Barre d. Quadriplegia

a. Amyotrophic lateral sclerosis

A patient has just undergone spinal fusion surgery and returned from the OR 12 hrs ago. Which task is best to delegate to UAP? a. Assist the nurse to log-roll the patient every 2 hrs. b. Help the pt dangle the legs c. Assist the pt to put on a brace d. Help the pt ambulate to the bathroom

a. Assist the nurse to log-roll the patient every 2 hrs.

The nurse is caring for a pt who has been in a long-term care facility for several months following an SCI. the pt has had problems with urinary retention and subsequent overflow incontinence, and a bladder retraining program was recently initiated. What is an expected outcome of the training program? a. Does not experience a UTI b. Catheterizes himself independently c. Controls incontinence by decreasing fluid intake d. Takes initiative to call for help when needed

a. Does not experience a UTI

The nurse is teaching a pt with multiple sclerosis and her family about her exercise program. Which points must the nurse include? Select all that apply. a. ROM exercises are an important component b. Stretching should precede rigorous activity c. Increased body temperature can lead to increased fatigue d. Steadily increasing walking distances can lead to jogging e. Stretching and strengthening exercises will be part of your program f. Take your pain medication at least 30 mins prior to exercise

a. ROM exercises are an important component c. Increased body temperature can lead to increased fatigue e. Stretching and strengthening exercises will be part of your program

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

a. Redness, warmth, and decreased ROM

A pt has just undergone spinal fusion and a laminectomy and has returned from the operating room. Which assessments are done in the first 24 hrs? Select all that apply. a. Take vital signs every 4 hrs and assess for fever and hypotension b. Perform a neuro assessment every 4 hrs with attention to movement and sensation c. Monitor I & O and assess for urinary retention d. Assess for ability and independence in ambulating and moving in bed e. Observe for clear fluid on or around the dressing f. Assess for and immediately report sudden onset of headache.

a. Take vital signs every 4 hrs and assess for fever and hypotension b. Perform a neuro assessment every 4 hrs with attention to movement and sensation c. Monitor I & O and assess for urinary retention e. Observe for clear fluid on or around the dressing f. Assess for and immediately report sudden onset of headache.

A pt is scheduled for lumbar surgery. Which key points must the nurse include in a pre-operative teaching plan for this patient? Select all that apply. a. Techniques for getting in and out of bed b. Expectations for turning and moving in bed c. Limitations and restrictions for home activities. d. Restricted to bed rest for at least 48 hrs e. Immediately report any numbness and tingling f. Expect difficulties moving affected leg or both legs

a. Techniques for getting in and out of bed b. Expectations for turning and moving in bed c. Limitations and restrictions for home activities. e. Immediately report any numbness and tingling f. Expect difficulties moving affected leg or both legs

The nurse is caring for a patient who is experiencing spinal shock. What are the expected findings that occur with the condition? a. Temporary loss of motor, sensory, reflex and autonomic functions. b. Stridor, garbled speech, or inability to clear airway c. Hypotension and a decreased LOC d. Bradycardia and decreased UO

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

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

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

A teenager dove head first into a rock quarry pond and is brought to the emergency department by EMS. Which questions will the nurse ask the EMS? Select all that apply. a. What were the location and position of the patient immediately after injury? b. Were there problems extricating the patient from the water? c. Have the parents been notified to get permission for treatment? d. What symptoms were reported by bystanders and noted en route? e. What changes occurred at the scene or en route? f. What treatments were given at the scene or en route?

a. What were the location and position of the patient immediately after injury? b. Were there problems extricating the patient from the water? d. What symptoms were reported by bystanders and noted en route? e. What changes occurred at the scene or en route? f. What treatments were given at the scene or en route?

Which position is therapeutic and comfortable for a patient with acute lower back pain from a herniated disc? a.Semi-Fowler's position with a pillow under the knees to keep them flexed. b. Supine position with arms and legs in a correct anatomical position. c. Orthopneic position; sitting with trunk slightly forward; arms supported with a pillow d. Modified Sim's position with upper arm and leg supported by pillows.

a.Semi-Fowler's position with a pillow under the knees to keep them flexed.

A patient reports increased fatigue and stiffness of the extremities. These symptoms have occurred in the past, but they resolved and no medication attention was sought. Which question does the nurse ask to assess whether the symptoms may be associated with MS? Select all that apply. a. "Are you having persistent headaches that occur with stress?" b. "Do you have a persistent sensitivity to temperature?" c. "Do you ever have slurred speech or trouble swallowing?" d. "Are you having trouble breathing with minimal exertion?" e. "Has anyone in your family been diagnosed with multiple sclerosis?" f. "Do you have spasms at night that wake you from your sleep?"

b. "Do you have a persistent sensitivity to temperature?" c. "Do you ever have slurred speech or trouble swallowing?" e. "Has anyone in your family been diagnosed with multiple sclerosis?" f. "Do you have spasms at night that wake you from your sleep?"

A pt with MS is prescribed oral fingolimod. Which key point must the nurse teach the patient about this drug? a. "You must be carefully monitored for allergic reactions bc the drug tends to build up in the body." b. "We need to teach you how to monitor your pulse rate bc this drug can cause a slow heart rate." c. "This drug will decrease the frequency of clinical relapses, but there is an increased risk for stroke." d. "The medication will improve your ability to walk, but it also increases the risk for seizures."

b. "We need to teach you how to monitor your pulse rate bc this drug can cause a slow heart rate."

The nurse is caring for several patients on an orthopedic surgical unit. Which pt has the greatest risk for fat embolism syndrome? a. 66 year old who had laser-assisted laparoscopic lumbar discectomy b. 46 year old who had a spinal fusion for spine stabilization c. 52 year old who had a laminectomy to relieve back pain d. 62 year old who had minimally invasive surgery

b. 46 year old who had a spinal fusion for spine stabilization

The nurse is preparing to physically assess a pt's report of parasthesia in the lower extremities. To accomplish this assessment, which assessment technique does the nurse use? a. Use a doppler to locate the pedal pulse, the dorsalis pedis pulse, or the popliteal pulse. b. Ask the patient to identify sharp and dull sensation by using a paper clip and a cotton ball. c. Use a reflex hammer to test for deep tendon patellar or Achilles reflexes. d. Ask the patient to walk across the room and observe gait and equilibrium.

b. Ask the patient to identify sharp and dull sensation by using a paper clip and a cotton ball.

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

b. Assess the respiratory pattern and ensure a patent airway

The pt with MS has dysarthria. What assessment would the nurse perform to monitor for a likely coexisting complication? a. Watch the patient walk and note smoothness of movement b. Check the pt's gag reflex and ability to swallow c. Ask the pt to use a pencil to write a sentence d. Have the pt stand and close eyes, and observe the pt for sway.

b. Check the pt's gag reflex and ability to swallow

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

b. Displays inability or difficulty moving extremities

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

b. Driving

The nurse is planning care for a 66 year old pt with SCI. Based on the nurse's knowledge of the most likely complication and cause of death for this patient, what would the nurse recommend? a. Increase calcium intake and exercise against resistance b. Ensure influenza and pneumococcus vaccinations are current c. Drink adequate liquids and eat a high-fiber diet d. Practice meticulous skin care; including frequent repositioning

b. Ensure influenza and pneumococcus vaccinations are current

Which symptoms indicate that a pt with a spinal cord injury is experiencing autonomic dysreflexia? Select all that apply. a. Flaccid paralysis b. Hypertension c. Tachypnea d. Severe headache e. Blurred vision f. Loss of reflexes below the injury

b. Hypertension d. Severe headache e. Blurred vision

The nurse is caring for several patients who have spinal cord injuries. Which task is best to delegate to UAP? a. Encourage use of incentive spirometry; evaluate the pt's ability to use it correctly b. Log-roll the pt; maintain proper body alignment and place a bedpan for toileting c. Check for skin breakdown under the immobilization devices during bathing d. Insert an indwelling catheter and report the amt and color of the urine

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

The nurse is caring for a pt with recent SCI. Which interventions does the nurse use to target and prevent the potential SCI complication of autonomic dysreflexia? Select all that apply. a. Frequently perform passive ROM exercises b. Loosen or remove any tight clothing c. Monitor stool output and maintain a bowel program d. Keep the pt immobilized with neck or back braces e. Monitor urinary output and check for bladder distention f. Maintain stable environmental temperature

b. Loosen or remove any tight clothing c. Monitor stool output and maintain a bowel program e. Monitor urinary output and check for bladder distention f. Maintain stable environmental temperature

The patient with chronic back pain is receiving ziconotide by intrathecal infusion with a surgically implanted pump. The patient develops hallucinations. What is the nurse's best first action? a. Request a psychiatric evaluation b. Notify the HCP c. Assess level of consciousness d. Decrease the dose of medication

b. Notify the HCP

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

b. Paraplegia

The nurse is assessing a patient who presented to the emergency department reporting acute onset numbness and tingling in the right leg. How does the nurse document this subjective finding? a. Paraparesis b. Parasthesia c. Ataxia d. Quadriparesis

b. Parasthesia

The nurse is assessing a pt with a spinal cord injury that occurred several months ago. The nurse recognizes that the patient is experiencing autonomic dysreflexia. What is the nurse's first priority action? a. Check for bladder distention b. Raise the head of bed c. Administer an anti-hypertensive med d. Notify the provider

b. Raise the head of bed

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

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

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

b. Turns the pt by grasping the top of the halo device

The home health nurse reads in the pt's chart that he has a spinal cord stimulator. What question would the nurse ask to evaluate the efficacy of the treatment? a. "Has the device helped you to gain control over the urinary incontinence?" b. "Does the device allow you to have sexual arousal that is satisfying?" c. "Have you been able to program the device to achieve maximum comfort?" d. "Have you programmed the device to achieve various levels of mobility?"

c. "Have you been able to program the device to achieve maximum comfort?"

The nurse is caring for a patient with a spinal cord injury who is experiencing neurogenic shock. The pt has a dopamine drip, but the systolic blood pressure is 88 mmHg. there is a new order to infuse 500 mL of dextran-40 over 4 hrs. At what rate does the nurse set the infusion pump? a. 75 mL/hr b. 100 mL/hr c. 125 mL/hr d. 150 mL/hr

c. 125 mL/hr

The pt with MS states she is bothered by diplopia. Which intervention does the nurse expect to implement? a. Obtain an order for consultation or referral for corrective lenses b. Teach the pt scanning techniques, moving her head from side to side c. Application of an eye patch alternating from eye to eye every few hours d. Prophylactic bilateral patches to both eyes at night.

c. Application of an eye patch alternating from eye to eye every few hours

The pt with a spinal cord injury has an HR of 42 bpm. Which drug does the nurse expect to administer? a. Methylprednisolone b. Dextran c. Atropine d. Dopamine

c. Atropine

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

c. Difficulties with situational coping

A patient tells the nurse, "I have symptoms of multiple sclerosis, and I have been dealing with them for so long! Why won't anyone help me?" Which intervention should the nurse employ first? a. Help the patient to locate and make an appointment with a specialist b. Ask the patient to describe the symptoms and past treatments c. Encourage the patient to verbalize feelings and frustrations d. Give the patient a brochure about the diagnosis and treatment of MS.

c. Encourage the patient to verbalize feelings and frustrations

What is a potential adverse outcome of autonomic dysreflexia in a patient with a spinal cord injury? a. Heatstroke b. Paralytic ileus c. Hypertensive stroke d. Aspiration and pneumonia

c. Hypertensive stroke

A pt has just undergone a laminectomy and returned from surgery at 1300 hours. At 1530 hrs, the nurse is performing the change of shift assessment. Which post-op finding is immediately reported to the surgeon? a. Some serosanguinous drainage b. Pain along the incision site c. Swelling or bulging at the operative site d. Reluctance or refusal to cough and breath deeply

c. Swelling or bulging at the operative site

The nurse has provided teaching to the husband of a 33 year old woman who was recently diagnosed with MS. Which statement by the pt's husband indicates he needs additional teaching on the course of the illness? a. "She could fall bc she may lose her balance and have poor coordination." b. "Eventually she will not be able to drive because of vision problems." c. "She will probably have a decreased libido and diminished orgasm." d. "As the disease progresses, she could have intermittent short-term memory loss."

d. "As the disease progresses, she could have intermittent short-term memory loss."

A patient had an anterior cervical discectomy with fusion and has returned from the recovery room. What is the priority assessment? a. Assess for gag reflex and ability to swallow own secretions. b. Check for bleeding and drainage at the incision site. c. Monitor vital signs and check neuro status. d. Assess for patency of airway and respiratory effort.

d. Assess for patency of airway and respiratory effort.

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

d. Venous thromboembolism