EAQ- Acute Neuro

A nurse is caring for a patient who has sustained a spinal cord injury. To prevent autonomic dysreflexia, the nurse should instruct the patient to avoid: 1 Urine retention 2 Emotional stress 3 Smoking cigarettes 4 People with upper respiratory infections

Answer: 1 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. Text Reference - p. 1479

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? 1 A virus causes inflammation, which leads to paralysis of the facial nerve. 2 A blood clot causes a small stroke, affecting the facial muscles. 3 The eustachian tube becomes blocked, leading to a bulging eardrum. 4 The flow of cerebrospinal fluid (CSF) in the brain is blocked temporarily.

Answer: 1 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. Text Reference - p. 1466

What nursing intervention should be implemented in the care of a patient who is experiencing increased intracranial pressure (ICP)? 1 Monitor fluid and electrolyte status carefully. 2 Position the patient in a high-Fowler position. 3 Administer vasoconstrictors to maintain cerebral perfusion. 4 Maintain physical restraints to prevent episodes of agitation.

Answer: 1 Fluid and electrolyte disturbances can have an adverse effect on ICP, and must be monitored vigilantly. The head of the patient's bed should be kept at 30 degrees in most circumstances, and physical restraints are not applied unless absolutely necessary. Vasoconstrictors typically are not administered in the treatment of ICP. Text Reference - p. 1367

Which manifestations in a patient with a T4 spinal cord injury should alert the nurse to the possibility of autonomic dysreflexia? 1 Headache and rising blood pressure 2 Irregular respirations and shortness of breath 3 Decreased level of consciousness or hallucinations 4 Abdominal distention and absence of bowel sounds

Answer: 1 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. Text Reference - p. 1479

The nurse is providing care to a patient with trismus. Which associated condition does the nurse suspect? 1 Tetanus 2 Botulism 3 Neurosyphilis 4 Guillain-Barré syndrome

Answer: 1 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. Text Reference - p. 1468

A patient with head trauma has a urine output of 300 mL/hr, dry skin, and dry mucous membranes. Which action should the nurse perform first? 1 Evaluate the urine specific gravity 2 Prepare the patient for acute hemodialysis 3 3.Continue to monitor urine output over the next hour 4 Slow the IV rate and notify the primary healthcare provider

Answer: 1 The patient is experiencing manifestations of diabetes insipidus related to a decrease in the pituitary gland production of ADH (antidiuretic hormone) as a result of a head injury. Without an adequate amount of ADH, the kidneys are unable to conserve water and therefore large fluid losses occur. The patient's problem is not related to renal failure, so there is no indication for hemodialysis. The primary healthcare provider should be notified of the increased urine output and results of the urine specific gravity, which will be low because of the diluted urine. After evaluation of the urine specific gravity the patient requires continued close monitoring of the urine output until seen by the primary healthcare provider. If the patient is found to have diabetes insipidus, the IV rate should not be slowed and will likely have to be increased to prevent dehydration. Text Reference - p. 1367

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? 1 Trismus is stiffness of the jaw and is one of the first manifestations of tetanus. 2 Trismus refers to spasms of the laryngeal and respiratory muscles and is one of the last stages of tetanus. 3 Trismus causes extreme arching of the back and retraction of the head and is unrelated to tetanus. 4 Trismus is the rigidity of neck muscles, back, abdomen, and extremities and is one of the first manifestations of tetanus.

Answer: 1 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 the disease tetanus. Other manifestations of tetanus include spasms of laryngeal and respiratory muscles, which could cause anoxia, extreme arching of the back and retraction of the head, also called opisthotonos, which is due to spasms of the trunk (back mainly) musculature. As the disease progresses, there is extreme rigidity of neck muscles, back, abdomen, and extremities. Text Reference - p. 1468

A patient with a suspected traumatic brain injury has bloody nasal drainage. What observation should cause the nurse to suspect that this patient has a cerebrospinal fluid (CSF) leak? 1 A halo sign on the nasal drip pad 2 Decreased blood pressure and urinary output 3 A positive reading for glucose on a Test-tape strip 4 Clear nasal drainage along with the bloody discharge

Answer: 1 When drainage containing both CSF and blood is allowed to drip onto a white pad, within a few minutes the blood will coalesce into the center, and a yellowish ring of CSF will encircle the blood, giving a halo effect. The presence of glucose would be unreliable for determining the presence of CSF because blood also contains glucose. Decreased blood pressure and urinary output would not be indicative of a CSF leak. Text Reference - p. 1369

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. 1 It supports facial muscles. 2 It facilitates eating. 3 It improves mouth alignment. 4 It improves cosmetic appearance. 5 It immobilizes the face, thereby preventing pain.

Answer: 1, 2, 3 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. Text Reference - p. 1467

When evaluating level of consciousness on the basis of Glasgow Coma Scale (GCS), which possible responses could be scored under best motor response? Select all that apply. 1 Flexion withdrawal 2 Localization of pain 3 Obedience of command 4 Opening the eyes in response to sound 5 Disorganized use of words

Answer: 1, 2, 3 Flexion withdrawal, localization of pain, and obedience of command can be recorded under best motor response. Opening of the eyes in response to stimuli and disorganized use of words are not recorded under motor response. Text Reference - p. 1365

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. 1 Dysrhythmias 2 Bradycardia 3 Orthostatic hypotension 4 Tabes dorsalis 5 Charcot's joints

Answer: 1, 2, 3 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. Text Reference - p. 1467

A patient has been diagnosed with trigeminal neuralgia. Which etiological factors should the nurse assess the patient for? Select all that apply. 1 Herpes virus infection 2 Infection of the teeth and jaw 3 Brainstem infarct 4 Sarcoidosis 5 Lyme disease

Answer: 1, 2, 3 The etiological factors of trigeminal neuralgia include herpes virus infection, infection of the teeth and jaw, and brainstem infarct. Sarcoidosis and Lyme disease do not cause trigeminal neuralgia and are etiological factors for Bell's palsy. Text Reference - p. 1464

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. 1 Independent self-care is possible. 2 Independent wheelchair mobility is possible. 3 Patient may be able to drive with hand controls. 4 Patient will be able to have effective coughing ability. 5 Patient will be able to climb stairs independently.

Answer: 1, 2, 3 The patient with a T3 level spinal cord injury will have full innervation of the upper extremities, back, essential intrinsic muscles of hand, 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 wheelchair, ability to drive a car with hand controls, independent standing in 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. Text Reference - p. 1473

The nurse is caring for a patient admitted for evaluation and surgical removal of a brain tumor. The nurse will plan interventions for this patient based on the knowledge that brain tumors can lead to which complications? Select all that apply. 1 Vision loss 2 Cerebral edema 3 Pituitary dysfunction 4 Parathyroid dysfunction 5 Focal neurologic deficits

Answer: 1, 2, 3, 5 Brain tumors can manifest themselves in a wide variety of symptoms depending on location, including vision loss and focal neurologic deficits. Tumors that put pressure on the pituitary can lead to dysfunction of the gland. As the tumor grows, clinical manifestations of increased intracranial pressure (ICP) and cerebral edema appear. The parathyroid gland is not regulated by the cerebral cortex or the pituitary gland. Text Reference - p. 1376

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. 1 The muscle responsible for breathing is paralyzed. 2 There is fluid overload in the lungs. 3 There is severe constriction of airways. 4 There is accumulation of secretions in the lungs, which has caused collapse of the lungs. 5 The nerve that controls breathing is damaged.

Answer: 1, 2, 4 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. Text Reference - p. 1471

A patient presents with hydrocephalus. When planning for patient care, which causes does the nurse determine could be a contributing factor? Select all that apply. 1 Obstruction to flow of cerebrospinal fluid (CSF) 2 Defective reabsorption of CSF 3 Rupture of cerebral blood vessels 4 Overproduction of CSF 5 Underproduction of CSF

Answer: 1, 2, 4 Hydrocephalus is the accumulation of CSF, which can be caused due to obstruction to flow of CSF and defective reabsorption and overproduction of CSF. Rupture of blood vessels causes intracranial bleeding. Underproduction of CSF is not a cause of hydrocephalus. Text Reference - p. 1379

When considering the use of temozolomide (Temodar) as a treatment for patients with a brain tumor, which factors should the nurse evaluate? Select all that apply. 1 Temozolomide (Temodar) can cross the blood-brain barrier. 2 Temozolomide (Temodar) causes myelosuppression. 3 Temozolomide (Temodar) causes photosensitivity. 4 Temozolomide (Temodar) can convert to an agent that directly interferes with tumor growth. 5 Temozolomide (Temodar) interacts with other drugs usually taken by brain tumor patients.

Answer: 1, 2, 4 Temozolomide (Temodar) can cross the blood-brain barrier. The drug is also known to cause myelosuppression; therefore, absolute neutrophil counts and platelet counts should be checked before starting the therapy. Temozolomide (Temodar) does not require metabolic activation to exert its effects and therefore can convert to an agent that directly interferes with tumor growth. It is not known to cause photosensitity or interact with other drugs usually taken by brain tumor patients. Text Reference - p. 1377

A patient has been diagnosed with a right-sided brain tumor resulting in significant increased intracranial pressure (ICP). The nurse can expect to document which assessment findings? Select all that apply. 1 Ipsilateral pupil dilation 2 Altered level of consciousness 3 Contralateral pupil dilation 4 Contralateral hemiparesis 5 Ipsilateral hemiparesis

Answer: 1, 2, 4 The level of consciousness is the most sensitive and reliable indicator of the patient's neurologic status. Patients experiencing increased intracranial pressure will present with varying degrees of altered levels of consciousness, depending on the degree of pressure. Compression of CN II (optic) results in dilation of the pupil on the same side (ipsilateral), not opposite (contralteral). As ICP continues to rise, the patient will experience changes in motor response on the opposite side of the lesion (contralateral), not the same side (ipsilateral). Text Reference - p. 1360

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. 1 Provide a pleasant eating environment. 2 Provide adequate time to eat. 3 Feed the patient only hospital-cooked food 4 Keep a calorie count of the food taken. 5 Encourage intake of dietary fiber. 6 Provide a low-protein and low-calorie diet.

Answer: 1, 2, 4, 5 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, as the patient could get 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. As there is severe catabolism taking place, a high-protein, high-calorie diet is necessary for energy and tissue repair. Text Reference - p. 1478

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. 1 "It is one of the most commonly diagnosed neuralgic conditions." 2 "Every year, about 150,000 Americans are diagnosed with this condition." 3 "It occurs twice as often in men than women." 4 "The cause and physical aspects of trigeminal neuralgia are not well known." 5 "90% of the cases occur in people over age 40." 6 "Risk factors include rheumatoid arthritis and primary epilepsy."

Answer: 1, 2, 4, 5 Trigeminal neuralgia is a common neuralgic condition with poorly known etiology and pathology that generally occurs in people over age 40. Each year about 150,000 Americans are diagnosed with this condition. The disease occurs more often in women than men. Risk factors include patients with herpes virus infections, infection of the teeth and jaw, and brain stem infarct.

When considering the use of hypertonic saline treatment in a patient with increased intracranial pressure (ICP), which factors should the nurse consider? Select all that apply. 1 Hypertonic saline treatment provides massive movement of water out of swollen brain cells. 2 The nurse should frequently monitor the blood pressure and sodium levels. 3 The nurse should closely monitor blood sugar levels in the patient. 4 The nurse should ensure that antacid is given to prevent gastrointestinal complications. 5 Hypertonic saline treatment works similar to mannitol in treating increased ICP.

Answer: 1, 2, 5 Hypertonic saline provides massive movement of water out of swollen brain cells and into blood vessels. When the patient is on this treatment, frequent monitoring of blood pressure and sodium levels are required, as intravascular fluid volume excess can occur. Hypertonic saline is as effective as mannitol in treating increased ICP. The treatment does not require monitoring of blood sugar levels, and antacids are not required to be given. Text Reference - p. 1364

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. 1 Assess thighs and calves for signs of DVT. 2 Obtain venous Doppler reports before applying compression stockings. 3 Perform passive movements with the patient once deep vein thrombosis is established. 4 Ensure that the patient wears compression stockings continuously throughout the day. 5 Administer prophylactic low dose low molecular weight heparin.

Answer: 1, 2, 5 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 8 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, as it may dislodge the thrombus, and pulmonary embolism, which is a life-threatening complication of DVT, may occur. Text Reference - p. 1478

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. 1 Check the patency of the urinary catheter. 2 Check the nutritional status of the patient. 3 Avoid lifting the patient when changing the position. 4 Change the position of the patient every 6 hours. 5 Check bony prominences for signs of pressure sores.

Answer: 1, 2, 5 Prevention of pressure ulcers and other types of injury to insensitive skin is essential for every patient with 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 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, as 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 2 hours. Text Reference - p. 1482

A patient on the intensive care unit has increased intracranial pressure (ICP) and a decreased level of consciousness. What actions should the nurse perform to prevent the patient from injury? Select all that apply. 1 Consider the use of light sedation agents. 2 Observe the skin area under the restraints. 3 Use a stimulating environment in the room. 4 Keep family members away from the patient. 5 Use effective restraints in an agitated patient.

Answer: 1, 2, 5 To prevent the patient from injury, the nurse should consider the use of light sedation agents, as prescribed by the health care provider. Skin area under the restraints should be checked for signs of irritation, as it can increase the patient's agitation. Using effective restraints in an agitated patient is advisable to ensure a secure outcome. The room should not have a stimulating environment; a calm, nonstimulating environment will help. Family members should not be prevented from visiting the patient. Instead allowing a family member may help to calm the patient. Text Reference - p. 1368

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. 1 Ensure regular and complete drainage of the bladder. 2 Start intermittent catheterization once the patient is stabilized. 3 Empty the urine bag whenever it is one-fourth filled. 4 Maintain the urine drainage bag above the level of the bladder. 5 Cleanse the patient's genitalia using antiseptic before placing the catheter.

Answer: 1, 2, 5 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 do is to use aseptic methods while inserting the catheter, like cleaning the genitalia using antiseptic. The urine bag should be drained every 8 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. Text Reference - p. 1481

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. 1 It helps to find the exact location of injury. 2 It helps to assess changes in the neurologic tissue. 3 It helps to find the degree of spinal canal compromise. 4 It helps to find the presence of any damage to the spinal or vertebral arteries. 5 It helps to diagnose deep vein thrombosis (DVT).

Answer: 1, 3 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. Text Reference - p. 1473

An elderly 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. 1 Hypotonicity of the lower limbs 2 Hypotonicity of the upper limbs 3 Urinary incontinence 4 Bowel incontinence 5 Difficulty in breathing

Answer: 1, 3, 4 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, as the injury is to the conus medullaris, which does not control muscles of breathing. Text Reference - p. 1484

A patient is diagnosed with a brainstem tumor. When assessing the patient, which symptoms would the nurse expect to find? Select all that apply. 1 Crossed eyes 2 Diabetes insipidus 3 Tinnitus and vertigo 4 Facial muscle weakness 5 Headache on awakening

Answer: 1, 3, 4 Crossed eyes, facial muscle weakness, and headache on awakening can be seen in brainstem tumors. Cerebellopontine tumors present with tinnitus, vertigo, and deafness. Diabetes insipidus is seen in thalamus and sellar tumors. Text Reference - p. 1376

A patient has been admitted with a T5 level spinal cord injury and has gastric distension. Which nursing interventions if prescribed would be appropriate for this patient? Select all that apply. 1 Place a nasogastric tube. 2 Administer laxatives. 3 Administer ranitidine (Zantac). 4 Administer metoclopramide (Reglan). 5 Administer metronidazole.

Answer: 1, 3, 4 Following a spinal cord injury at the level of T5, the patient may experience gastrointestinal problems (GI) problems related to hypomotility. Decreased GI motor activity contributes to the development of paralytic ileus and gastric distention. A nasogastric tube should be placed for intermittent suctioning to relieve the gastric distention. Metoclopramide may be used to treat delayed gastric emptying. The development of stress ulcers is common because of excessive release of hydrochloric (HCl) acid in the stomach; therefore, an antacid like ranitidine would be useful to relieve these. Laxatives are mostly useful for increasing the bulk of food, which is not suitable in this case. Metronidazole would be useful if any gastric infection has been established or is suspected. Text Reference - p. 1472

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. 1 Administer oxygen. 2 Administer steroids. 3 Use assisted coughing techniques. 4 Perform tracheal suctioning. 5 Administer antibiotic drugs.

Answer: 1, 3, 4 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, 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 in this patient. Text Reference - p. 1477

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. 1 Depression 2 Difficulty in swallowing food 3 Boredom due to institutional food 4 Hurried feeding by the nurse 5 Continuous bed rest and weakness 6 Abnormal taste sensation

Answer: 1, 3, 4, 5 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. Text Reference - p. 1478

When managing a fever in a patient with acute meningitis, what actions should the nurse perform? Select all that apply. 1 A cooling blanket can be used to reduce fever. 2 Shivering is good and will help reduce fever. 3 Reduce fever with the use of acetaminophen (Tylenol). 4 Reduce body temperature rapidly to provide relief. 5 Lower temperature by the use of tepid water sponge baths.

Answer: 1, 3, 5 A cooling blanket can be used to reduce fever, acetaminophen may be used to reduce fever, and tepid water sponge baths may be effective in lowering temperature. Shivering should be prevented, as it may cause a rebound effect and increase the temperature. Rapidly reducing temperature may result in shivering and is not advisable. Text Reference - p. 1383

When managing a patient with increased intracranial pressure, which actions should the nurse perform? Select all that apply. 1 Administer intubation and mechanical ventilation 2 Wait for the respiration to improve before beginning with ventilation. 3 Maintain fluid balance and assess osmolality. 4 Lower the head of the bed and turn the patient to one side. 5 Elevate the head of the bed to 30 degrees with the head in a neutral position.

Answer: 1, 3, 5 Intubation and mechanical ventilation, maintenance of fluid balance and assessment of osmolality, and elevation of head of bed to 30 degrees with head in a neutral position are the appropriate actions to be performed when managing a patient with increased intracranial pressure (ICP). Waiting for the respiration to improve may be life-threatening. Lowering of head of bed and turning the patient to one side may further increase the intracranial pressure. Text Reference - p. 1367

A patient with increased intracranial pressure (ICP) is being treated with corticosteroids. What actions should the nurse perform to avoid complications due to corticosteroid treatment? Select all that apply. 1 Monitor fluid intake and sodium levels regularly. 2 Monitor patient's sleep and diet routine regularly. 3 Perform blood glucose monitoring at least every 6 hours. 4 Avoid taking any antacids along with corticosteroid treatment. 5 Start concurrent treatment with antacids or proton pump inhibitors.

Answer: 1, 3, 5 Patients on corticosteroid treatment should be regularly monitored for fluid intake and sodium levels. Blood glucose monitoring should be performed at least every 6 hours until hyperglycemia is ruled out. Starting concurrent treatment with antacids or proton pump inhibitors is important to prevent gastrointestinal ulcers and bleeding, as complications associated with the use of corticosteroids include hyperglycemia, increased incidence of infections, and gastrointestinal bleeding. Regularly monitoring the patient's sleep and diet routine does not contribute to avoiding complications related to corticosteroid therapy. Antacids should be given along with corticosteroids to prevent gastrointestinal complications. TEST-TAKING TIP: Try putting questions and answers in your own words to test your understanding. Text Reference - p. 1367

When performing a neurological assessment on a patient, the nurse notes fixed pupils that are unresponsive to a light stimulus. Which causes of fixed pupils should the nurse consider during this assessment? Select all that apply. 1 Previous eye surgery 2 Administration of diuretics 3 Increased intraocular pressure 4 Increased intracranial pressure (ICP) 5 Direct injury to the third cranial nerve (CN III)

Answer: 1, 4, 5 A fixed pupil unresponsive to light stimulus usually indicates a previous eye surgery, increased ICP, direct injury to CN III, administration of atropine, and use of mydriatic eye drops. Administration of diuretics and increased intraocular pressure do not cause fixed pupil. Text Reference - p. 1366

A patient presents with a head injury and the nurse suspects a temporal fracture. Which manifestations should the nurse assess further? Select all that apply. 1 Cerebrospinal fluid (CSF) otorrhea 2 Optic nerve injury 3 Periorbital ecchymosis 4 Boggy temporal muscle 5 Oval-shaped bruise in the mastoid region

Answer: 1, 4, 5 A temporal fracture may manifest as CSF otorrhea, boggy temporal muscle because of extravasation of blood, and oval-shaped bruise behind ear in the mastoid region (Battle's sign). Optic nerve injury and periorbital ecchymosis are found in occipital fracture. Text Reference - p. 1369

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. 1 Cleanse the catheter regularly. 2 Always keep the urine bag above the waist. 3 Limit water intake to less than a litre a day. 4 Check for the presence of any folds or kinks in the catheter tube. 5 Check for signs of urinary tract infection (fever, change in odor or color of urine).

Answer: 1, 4, 5 Indwelling catheters should be cleaned regularly, and the method of cleaning should be taught properly by the nurse to the patient as 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). Text Reference - p. 1481

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. 1 There is loss of nervous control of the blood vessels. 2 Blood pressure and heart rate have increased. 3 Blood vessels in the extremities have constricted. 4 There is pooling of blood in the veins of the extremities. 5 The amount of blood pumped out of the heart reduces.

Answer: 1, 4, 5 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, and not increased blood pressure and heart rate. The blood vessels in the extremities dilate due to neurogenic shock. Text Reference - p. 1470

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. 1 These spasms can occur as a result of a variety of stimuli. 2 This occurs due to hyperexcitability of the upper motor neuron. 3 These spasms indicate improvement in the condition of the patient. 4 Such reflexes could be positively used for bowel and bladder retraining. 5 This occurs due to a break in the link between the upper and lower motor neuron interaction.

Answer: 1, 4, 5 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 Text Reference - p. 1479

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. 1 Insert a nasogastric tube. 2 Evaluate swallowing before starting oral feeding. 3 Gradually introduce oral food and fluids, irrespective of bowel sounds. 4 Prescribe a low-protein and low-carbohydrate diet. 5 If oral feeding is not possible, enteral nutrition must be provided.

Answer: 1,2, 5 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. Text Reference - p. 1468

A patient who presented 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. 1 Stabilization of blood pressure and pulse rate. 2 Lung vital capacity and arterial blood gases are stable. 3 Symptoms of paralysis stop progressing and abate. 4 Blood urea nitrogen (BUN) and creatinine levels are within normal levels. 5 Urinary output is at least 30 mL per hour.

Answer: 1,2,3 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. Text Reference - p. 1468

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. 1 Use pressure-relief devices while sitting. 2 Change position at least every two hours. 3 Apply massage to areas with sustained redness. 4 Follow a diet high in vitamins and low in protein. 5 Inspect all skin areas on a daily basis using a mirror as necessary.

Answer: 1,2,5 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. Text Reference - p. 1482

The nurse is assessing a fully alert healthy patient. What grade should the nurse give the patient on the Glasgow Coma Scale (GCS)? Record your answer as a whole number.

Answer: 15 The highest GCS score is 15 for a fully alert person. Text Reference - p. 1365

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? 1 Central cord syndrome 2 Spinal shock syndrome 3 Anterior cord syndrome 4 Brown-Séquard syndrome

Answer: 2 About 50% 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 greater in the upper extremities than 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. Text Reference - p. 1470

A patient with facial paralysis comes to the walk-in clinic and is diagnosed with Bell's palsy. The clinic nurse knows that this condition: 1 Has a poor prognosis 2 Can affect any age group 3 Can occur on both sides of the face. 4 Affects more than 100,000 people every year

Answer: 2 Bell's palsy is a type of peripheral facial paralysis that can affect any age group, although it commonly is seen in the 20--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), but 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. Text Reference - p. 1541

What health promotion activity will have the greatest impact in the prevention of spinal cord injury (SCI) in adults 65 years and older? 1 Hearing testing 2 Fall prevention strategies 3 Depression screenings 4 Monitoring blood pressure

Answer: 2 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. Text Reference - p. 1484

Which diagnostic test would the nurse anticipate to further localize and detect blood flow for a patient with a brain tumor? 1 Electroencephalogram (EEG) 2 Angiography 3 Lumbar puncture 4 Endocrine studies

Answer: 2 For a patient with brain tumor, angiography can be used to localize the tumor and determine blood flow. EEG helps to detect seizures. Lumbar puncture does not detect the blood flow to the tumor and involves additional risk. Endocrine studies are helpful when a pituitary adenoma is suspected. Text Reference - p. 1377

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? 1 Monitoring vital signs 2 Maintaining a patent airway 3 Maintaining proper body alignment 4 Turning and repositioning the patient every 2 hours

Answer: 2 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 of as high of a priority as maintaining a patent airway is. Turning and repositioning the patient every 2 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. Text Reference - p. 1473

The nurse is caring for a patient with poikilothermia. What condition in the patient's medical record likely caused this clinical manifestation? 1 Polyneuropathy 2 Spinal cord injury 3 Spinal cord tumor 4 Cranial nerve disorder

Answer: 2 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, knife-like 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. Text Reference - p. 1473

A patient with a head injury has a score of 5 on the Glasgow Coma Scale. How should the nurse interpret the score? 1 The patient is alert and oriented. 2 The patient is unresponsive and comatose. 3 The patient is awake but lethargic and drowsy. 4 The patient responds appropriately to commands.

Answer: 2 The Glasgow Coma Scale ranges from 3 to 14. A score of 7 or less indicates that a patient is in a coma. The lower the score, the more serious the patient's condition. A patient who is alert and orient, awake but lethargic, or responding appropriately to commands has a Glasgow Coma Scale score higher than 7. Text Reference - p. 1365

A patient has been admitted to the hospital with 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 injury above T12? Select all that apply. 1 The sensation of a full bowel is perceived by the patient, and fecal incontinence is present. 2 The sensation of a full bowel is not perceived by the patient, and fecal incontinence is present. 3 There is excess gastric distention, and the stomach is hard. 4 The patient is constipated and is passing hard stools with straining. 5 The patient has absence of bowel sounds.

Answer: 2, 3 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, a 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, then 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. Text Reference - p. 1472

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. 1 Vasodilator drugs 2 Atropine (Atropen) 3 Vasopressor drugs 4 Digoxin (Lanoxin) 5 Metoclopramide (Reglan)

Answer: 2, 3 Due to the spinal cord injury at 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, therefore 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. Text Reference - p. 1475

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. 1 Signs of any infection 2 Signs of any internal bleeding 3 Any history of recent surgeries 4 Signs of any respiratory distress 5 Gastroenteritis

Answer: 2, 3 Low-molecular-weight heparin (e.g., enoxaparin [Lovenox]) 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. Text Reference - p. 1475

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. 1 Teach Valsalva maneuver. 2 Explain the usage of stool softeners. 3 Teach to perform digital stimulation of the rectum. 4 Advise the use of suppositories for evacuation. 5 Advise to have a high-fiber diet. 6 Advise to limit fluids in the diet.

Answer: 2, 3, 4, 5 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 (Colace) 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 [Dulcolax] 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. High intake of fluid is advised for easy bowel evacuation. Text Reference - p. 1481

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. 1 The injury does not cause amenorrhea. 2 The patient does have the capacity to become pregnant. 3 Precautions for unplanned pregnancy are necessary. 4 Erotic and sexual thoughts may not cause vaginal lubrication to take place. 5 Fatal complications like autonomic dysreflexia could be associated with pregnancy.

Answer: 2, 3, 4, 5 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 6 months after the spinal cord injury. The woman of childbearing age with an SCI usually remains fertile. Text Reference - p. 1482

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. 1 In Bell's palsy, muscles of mastication are paralyzed. 2 There is pain around the jaw, which prevents the proper chewing of food. 3 There is accumulation of food on one side of the mouth. 4 The sensation inside the mouth is affected. 5 The taste sensation is impaired.

Answer: 2, 3, 5 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, as it is carried by the trigeminal nerve. Text Reference - p. 1467

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. 1 Grimacing and frequent blinking 2 Flaccidity of the affected side of the face 3 Drooping of the mouth accompanied by drooling 4 Narrowed palpebral fissure 5 Flattening of the nasolabial fold

Answer: 2, 3, 5 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. Text Reference - p. 1466

When teaching a patient about care after a head injury, which important symptoms should the nurse instruct the patient and caregiver to immediately notify a health care provider about? Select all that apply. 1 Sneezing 2 Seizures 3 Stiff neck 4 Constipation 5 Increased drowsiness

Answer: 2, 3, 5 Seizures, a stiff neck, and increased drowsiness are the important symptoms that the patient and caregivers should immediately relay to the health care provider. Sneezing and constipation are not alarming and can also be due to other reasons. Text Reference - p. 1374

When planning pharmacologic therapy for a patient with increased intracranial pressure (ICP), which factors should the nurse consider? Select all that apply. 1 Use benzodiazepines as a standalone treatment for sedation. 2 Monitor for hypotension when using opioids to manage anxiety. 3 Monitor for hypotension when using continuous intravenous sedatives. 4 Use nondepolarizing neuromuscular blocking agents alone for better outcomes. 5 Use sedatives or analgesics with nondepolarizing neuromuscular blocking agents.

Answer: 2, 3, 5 The appropriate factors to evaluate include monitoring for hypotension when using opioids to manage anxiety and monitoring for hypotension when using continuous intravenous sedatives, as hypotension is a side effect. Using sedatives or analgesics with nondepolarizing neuromuscular blocking agents are important because these agents paralyze muscles without blocking pain or noxious stimuli. Using benzodiazepines as a standalone treatment for sedation is not advisable due to their hypotensive effects and long half-life. Nondepolarizing neuromuscular blocking agents paralyze muscles without blocking pain or noxious stimuli; they are used in combination with sedatives, analgesics, or benzodiazepines. Text Reference - p. 1364

A patient is suspected of having cervical cord injury following a motor vehicle accident. Which nursing interventions are appropriate for this patient to stabilize his cervical spine? Select all that apply. 1 Use a soft cervical collar to stabilize the cervical spine. 2 Use a firm backboard to prevent any spinal movement. 3 Ensure that the patient's body is correctly aligned. 4 Avoid logrolling of the patient. 5 Use a sternal-occipital-mandibular immobilizer brace.

Answer: 2, 3, 5 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. Text Reference - p. 1474

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. 1 Patient avoids sleeping. 2 Patient has stopped eating. 3 Patient avoids blinking the eye. 4 Patient covers the face with a cloth. 5 Patient avoids interacting with people.

Answer: 2, 4, 5 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. Text Reference - p. 1464

When planning the body position of a patient with increased intracranial pressure (ICP), which factors should the nurse consider? Select all that apply. 1 Raising the head of bed above 30 degrees 2 Maintaining a head up position for the patient 3 Placing the patient in side lying position 4 Taking care to prevent extreme neck flexion of patient 5 Adjusting the patient's body position to decrease intracranial pressure (ICP)

Answer: 2, 4, 5 Maintaining a head up position for the patient is important, as elevation of the head of the bed promotes drainage and decreases the vascular congestion that can produce cerebral edema. The nurse should take care to prevent extreme neck flexion of the patient because it can cause venous obstruction and contribute to elevated ICP. The patient's body position should be adjusted to decrease ICP and improve the cerebral perfusion pressure (CPP). Raising the head of the bed above 30 degrees is not advisable, as it may decrease the CPP by lowering systemic blood pressure (BP). Maintaining a side lying position may further increase the ICP. Text Reference - p. 1367

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. 1 The patient's ability to have psychogenic erections is not affected. 2 Patient may have erectile dysfunction that can be treated. 3 Male fertility will not be affected by the injury. 4 A reflex erection could be easily elicited in the patient. 5 Vacuum suction devices help in improving blood flow to the penis.

Answer: 2, 4, 5 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 S2-4 nerve pathways are not damaged. Treatment for erectile dysfunction includes drugs, vacuum devices, and surgical procedures. In case 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. Text Reference - p. 1482

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. 1 Patient will be well-sedated during this procedure. 2 Patient may experience facial numbness after the surgery. 3 A small craniotomy will be performed behind the ear. 4 Patient may have difficulty in masticating effectively for some time after the procedure. 5 Patient may have difficulty with eye movements after the procedure.

Answer: 2, 4, 5 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, as it only involves placing a needle. A craniotomy is required in microvascular decompression of the trigeminal nerve. Text Reference - p. 1465

When educating the patient about ways to prevent head injuries, which measures should the nurse counsel this patient? Select all that apply. 1 Use of carpooling 2 Use of car seat belts 3 Use of tinted glasses 4 Use of child car seats 5 Use of helmets by cyclists

Answer: 2, 4, 5 Using car seat belts, using child car seats, and using helmets by cyclists can help to prevent head injuries. Use of carpooling and use of tinted glasses do not help to reduce the rate of head injuries. Text Reference - p. 1373

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 should be the focus of collaborative care? Select all that apply. 1 Administration of facial sling to support affected muscles 2 Tracheostomy for mechanical ventilation 3 Administration of polyvalent antitoxin 4 Teaching correct processing of canned foods 5 Control of spasms with diazepam (Valium)

Answer: 2, 5 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. Text Reference - p. 1468

The nurse is performing an initial assessment on a patient to obtain baseline data about the patient's neurological status. Which actions should the nurse perform relevant to a neurological assessment? Select all that apply. 1 Assess patient's temperature and pulse rate. 2 Assess patient when performing daily activities. 3 Assess patient's integrated function and balance. 4 Assess patient's weight, height, and waist-to-hip ratio. 5 Assess patient's level of consciousness and motor abilities.

Answer: 2,3,5 A neurological assessment includes assessment of patient when performing daily activities, assessment of integrated function and balance, and assessment of the level of consciousness and motor abilities. Assessing the patient's temperature and pulse rate and assessing patient's weight, height, and waist-to-hip ratio are general measurements and are not included for neurological status measurement. Text Reference - p. 1378

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. 1 Withhold antacids. 2 Check stools for blood. 3 Obtain prescriptions for increased dosage of corticosteroids. 4 Administer proton pump inhibitors for prophylaxis as prescribed. 5 Motivate the patient and provide a stress-free environment.

Answer: 2,4, 5 In spinal cord injuries, stress ulcers is 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 (H2)-receptor blockers like ranitidine (Zantac) or proton pump inhibitors like pantoprazole (Protonix) 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. Text Reference - p. 1479

When evaluating the diagnostic studies for a patient with bacterial meningitis, which factors should the nurse consider regarding lumbar puncture? Select all that apply. 1 Lumbar puncture may require a contrast to be injected. 2 Lumbar puncture is done to analyze cerebrospinal fluid (CSF) in case of bacterial meningitis. 3 Lumbar puncture is helpful in confirming diagnosis of brain tumor. 4 Lumbar puncture is done after ruling out an obstruction in the foramen magnum. 5 Lumbar puncture is usually helpful in confirming the diagnosis of bacterial meningitis.

Answer: 2,4, 5 Lumbar puncture is done to analyze CSF in case of bacterial meningitis and is done after ruling out an obstruction in the foramen magnum to prevent a fluid shift resulting in herniation. Lumbar puncture is usually helpful in verifying the diagnosis of bacterial meningitis. Lumbar puncture does not involve injection of contrast medium. The procedure is not helpful in confirming the diagnosis of brain tumor. Text Reference - p. 1382

After undergoing surgery for resection of a brain tumor, a patient arrives in the postanesthesia care unit with a temperature of 100° F (37.7° C), blood pressure of 130/76 mm Hg, pulse 64 beats/min, a urinary catheter in place, and oxygen being administered at a rate of 2 L/min by way of a nasal cannula. One hour later, the nurse assesses the patient. Which assessment finding does the nurse realize should be reported immediately to the surgeon? 1 Presence of a gag reflex 2 Urine output of 50 mL during the past hour 3 Blood pressure of 148/58 mm Hg and pulse 48 beats/min 4 Temperature of 99.8° F (37.6° C) and pulse of 96 beats/min

Answer: 3 A blood pressure with a widening pulse pressure, bradycardia, and irregular respirations are associated with increasing intracranial pressure (ICP). This is known as the Cushing's triad and should be reported immediately. Presence of a gag reflex, urine output of 50 mL over an hour, and temperature of 99.8° F (37.6° C) and pulse of 96 beats/min are acceptable assessment findings in a postoperative patient. Text Reference - p. 1360

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 (Decadron) is prescribed. What is the desired effect of the medication? 1 Improve muscular strength in the lower extremities. 2 Lower the systolic blood pressure. 3 Decrease tumor-related edema. 4 Control elevated serum glucose levels.

Answer: 3 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. Text Reference - p. 1485

In planning long-term care for a patient after a craniotomy, what must the nurse include when teaching the patient, family, and caregiver? 1 Seizure disorders may occur in weeks or months. 2 The family will be unable to cope with role reversals. 3 There are often residual changes in personality and cognition. 4 Referrals will be made to eliminate residual deficits from the damage.

Answer: 3 In long-term care planning, the nurse must include the family and caregiver when teaching about potential residual changes in personality, emotions, and cognition, as these changes are most difficult for the patient and family to accept. Seizures may or may not develop. The family and patient may or may not be able to cope with role reversals. Although residual deficits will not be eliminated with referrals, they may be improved. Text Reference - p. 1374

The nurse administers mannitol (Osmitrol) that has been prescribed for a patient with increased intracranial pressure. What is the primary expected outcome? 1 Increased urine output 2 Decreased blood pressure Correct 3 Reduced intracranial pressure 4 Increased intracranial perfusion

Answer: 3 Mannitol (Osmitrol) is an osmotic diuretic that increases osmotic pressure in the renal tubules. This increases uptake of water and diuresis, which specifically helps relieve cerebral edema, thereby decreasing intracranial pressure. Increased urine output, decreased blood pressure, and increased intracranial perfusion are secondary outcomes of administration of mannitol (Osmitrol). Of these, increased intracranial perfusion is most desirable because it reduces intracranial pressure. Blood pressure must be monitored closely because an extreme decrease in blood pressure may occur, resulting in decreased intracranial perfusion. Text Reference - p. 1364

A patient has a systemic blood pressure of 120/60 and an intracranial pressure (ICP) of 24 mm Hg. After calculating the patient's cerebral perfusion pressure (CPP), how does the nurse interpret the results? 1 High blood flow to the brain 2 Normal intracranial pressure 3 Impaired blood flow to the brain 4 Adequate autoregulation of blood flow

Answer: 3 Normal CPP is 60 to 100 mm Hg. The CPP is calculated with mean arterial pressure (MAP) minus ICP. MAP = systolic blood pressure (SBP) + 2 (diastolic blood pressure [DBP])/ 3: 120 mm Hg + 2 (60 mm Hg)/3 =80 mm Hg. MAP-ICP: 80mm Hg-24 mm Hg = 56 mm Hg CPP. The decreased CPP indicates that there is impaired cerebral blood flow and that autoregulation is impaired. Because the ICP is 24, it is elevated and requires treatment. Text Reference - p. 1357

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. 1 Administration of antiseizure medications 2 Preparing for a nerve block to relieve pain 3 Administration of corticosteroid medications 4 Dark glasses and artificial tears to protect the eyes 5 Surgeries available if conservative therapy is not effective

Answer: 3, 4 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 . Text Reference - p. 1466

The nurse is assessing a comatose patient. Which findings would the nurse observe? Select all that apply. 1 Patient can cough and swallow. 2 Patient has bowel and bladder control. Correct 3 Patient's corneal and pupillary reflexes are absent. Correct 4 Patient has incontinence of urine and feces. Correct 5 Patient does not respond to painful stimuli.

Answer: 3, 4, 5 A coma is the deepest state of unconsciousness in which the corneal and pupillary reflexes are absent. A comatose patient is also incontinent of urine and feces and does not respond to painful stimuli. The comatose patient is not able to cough and swallow and does not have any bowel and bladder control. Text Reference - p. 1365

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. 1 Involuntary stool 2 Severe drop in blood pressure 3 Sudden onset of severe headache 4 Sweating above the level of the SCI 5 Flushed face and chest above the level of the SCI

Answer: 3, 4, 5 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 caused by the SCI. Thus the patient develops severe hypertension, often with bradycardia. The causative factor also includes 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 causes 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. Text Reference - p. 1479

When managing a patient with suspected bacterial meningitis, what immediate actions should the nurse perform? Select all that apply. 1 Wait and watch till the fever reduces and next signs appear. 2 Wait for a confirmed diagnosis before starting antibiotics. 3 Collect specimens for a culture to confirm the diagnosis. 4 Administer a corticosteroid along with the first dose of antibiotics. 5 Initiate antibiotic therapy without waiting for a confirmed diagnosis.

Answer: 3, 4, 5 Collecting specimens to confirm the diagnosis and administering corticosteroids and antibiotics are the measures that must be taken immediately, as bacterial meningitis is a medical emergency. Waiting and watching until the fever reduces and the next signs of meningitis appear and waiting for a confirmed diagnosis before starting antibiotics are not advisable as they may aggravate the condition and may become life-threatening. Text Reference - p. 1282

A patient presents with a headache, which is worse in the morning and is aggravated with movements. The patient also complains of vomiting without any preceding nausea. When assessing the patient, which common causes should the nurse consider when suspecting increased intracranial pressure? Select all that apply. 1 Sinusitis 2 Glaucoma 3 Hematoma 4 Head injury 5 Brain tumor

Answer: 3, 4, 5 Common causes of increased intracranial pressure include a mass-like hematoma or tumor and cerebral edema due to brain tumors or hydrocephalus, head injury, or brain inflammation. Sinusitis and glaucoma do not cause an increase in intracranial pressure. Text Reference - p. 1359

When assessing a patient suspected of having a brain tumor, which diagnostic procedure can the nurse anticipate for an accurate diagnosis? Select all that apply. 1 Computed tomography (CT) scan 2 Lumbar puncture 3 Electron microscopy 4 Immunohistochemical stains 5 Computer-guided stereotactic biopsy

Answer: 3, 4, 5 Electron microscopy, immunohistochemical stains, and computer-guided stereotactic biopsy can help in the correct diagnosis of a brain tumor. EEG helps to detect seizures. Lumbar puncture does not detect the blood flow to tumor and involves additional risk. Text Reference - p. 1377

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. 1 Include beans in the diet to increase fiber intake. 2 Include spicy food to improve taste. 3 Eat three well-balanced meals each day. 4 Include two servings from the milk group. 5 Include two or more servings from the meat group.

Answer: 3, 4, 5 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, as they can cause formation of gas. Spicy food should also be avoided, as it can cause gastrointestinal upset. Text Reference - p. 1478

When managing the routine daily care of a patient with acute meningitis, which actions should the nurse perform? Select all that apply. 1 Lower the head of the bed. 2 Instruct the patient to ambulate or walk around the room. 3 Place the patient in a comfortable position. 4 Position the patient in a curled up position with the head slightly extended. 5 Slightly elevate the head of the bed if permitted after lumbar puncture.

Answer: 3, 4, 5 In acute meningitis, the nurse should assist the patient to a comfortable position; often, curled up with the head slightly extended is best. The head of the bed should be slightly elevated when permitted after lumbar puncture. Lowering the head of bed may increase headaches in the patient. Making the patient walk in the room is not advisable, as movement can aggravate the head and neck pain. The patient with meningitis may have delirium, and making the patient walk may increase risk of injury. Text Reference - p. 1383

The nurse uses the Glasgow Coma Scale (GCS) to establish a baseline of the patient's neurologic function. The GCS evaluates which of the following? Select all that apply. 1 Orientation 2 Cognition 3 Ability to speak 4 Ability to follow commands 5 Eye opening responses stimuli

Answer: 3, 4, 5 The GCS is a standardized tool for assessing the level of consciousness. The three areas that are assessed include the patient's ability to speak, obey commands, and open the eyes to verbal or painful stimuli. This tool does not assess orientation (Where are you? What is your name? What day is it?), or cognition (i.e. adding three numbers). The GCS results are used to determine the stability of the patient's condition. Text Reference - p. 1365

Which surgical techniques and procedures are used to localize brain tumors intraoperatively? Select all that apply. 1 Electroencephalogram (EEG) 2 X-ray 3 Ultrasound 4 Functional magnetic resonance imaging (MRI) 5 Cortical mapping 6 Computer-guided stereotactic biopsy

Answer: 3, 4, 5, 6 Techniques like ultrasound, functional MRI, cortical mapping, and computer-guided stereotactic biopsy can be used to localize brain tumors intraoperatively. EEG is used to rule out seizure disorder. X-ray is used to show the changes in the skull but may not show soft tissue changes due to brain tumor. Text Reference - p. 1377

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. 1 If in a wheelchair, lift self up and shift weight every 2 to 4 hours. 2 If in bed, change positions using a regular turning schedule of 6 hours. 3 Use special mattresses to reduce pressure. 4 Use wheelchair cushions to reduce pressure. 5 Use pillows to protect bony prominences when in bed.

Answer: 3,4,5 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 self up and shift weight every 15-30 minutes to promote circulation. If in bed, position should be changed every 2 hours. Text Reference - p. 1482

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? 1 Supine position 2 Prone position 3 Standing position 4 Sitting position

Answer: 4 A patient with T7 level spinal injury will be able to sit; therefore, it is best to position the patient upright for proper evacuation, as this position would ensure complete evacuation. 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. Prone position and standing is awkward for bowel evacuation. Text Reference - p. 1479

A patient suffered a diffuse axonal injury from a traumatic brain injury (TBI). The patient has been maintained on intravenous (IV) fluids for two days. The nurse seeks enteral feeding for this patient based on what rationale? 1 Free water should be avoided 2 Sodium restrictions can be managed 3 Dehydration can be avoided better with feedings 4 Malnutrition promotes continued cerebral edema

Answer: 4 A patient with diffuse axonal injury is unconscious, and with increased ICP is in a hypermetabolic, hypercatabolic state that increases the need for fuel for healing. Malnutrition promotes continued cerebral edema and early feeding may improve outcomes when begun within three days after injury. Fluid and electrolytes will be monitored to maintain balance with the enteral feedings. Text Reference - p. 1370

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? 1 It blocks the perception of pain sensation. 2 It anesthetizes the area supplied by the trigeminal nerve. 3 It reduces the pain by treating underlying depression. 4 It attenuates the transmission of nerve impulses from the trigeminal nerve.

Answer: 4 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. Text Reference - p. 1464

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? 1 Central cord syndrome 2 Anterior cord syndrome 3 Cauda equina syndrome 4 Brown-Séquard syndrome

Answer: 4 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? 1 Central cord syndrome 2 Anterior cord syndrome 3 Posterior cord syndrome 4 Brown-Séquard syndrome

Answer: 4 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. Text Reference - p. 1472

The nurse is providing care to a patient with a spinal cord injury who has areflexic bladder. Which syndrome does the nurse anticipate? 1 Central cord syndrome 2 Posterior cord syndrome 3 Brown-Séquard syndrome 4 Conus medullaris syndrome

Answer: 4 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. Text Reference - p. 1472

A patient with a head injury presents to the emergency department. Which potential complication related to cerebral hemorrhage and edema should the nurse evaluate this patient for? 1 Anxiety 2 Hyperthermia 3 Impaired physical mobility 4 Increased intracranial pressure

Answer: 4 Increased intracranial pressure can occur as a potential complication related to cerebral hemorrhage and edema. Anxiety can result from an abrupt change in health status, being in a hospital environment, and having an uncertain future. Hyperthermia can occur due to increased metabolism, infection, and hypothalamic injury. Impaired physical mobility is related to a decreased level of consciousness. Text Reference - p. 1358

A patient is admitted to the emergency department with a closed head injury. The patient is awake but lethargic, and the baseline vital signs include a blood pressure of 120/80 mm Hg, pulse of 78 beats/min, and respirations of 20 breaths/min. Two hours later the nurse assesses the patient. Which finding indicates a deterioration in the patient's condition? 1 The patient does not remember what happened. 2 The patient is sleeping but awakens in response to painful stimuli. 3 Blood pressure is 110/80 mm Hg. pulse is 78 beats/min, and respirations are 20 breaths/min. 4 Blood pressure is 160/74 mm Hg, pulse is 53 beats/min, and respirations are 10 breaths/min.

Answer: 4 Late signs of increased intracranial pressure include an increased systolic blood pressure and decreasing diastolic blood pressure (widening pulse pressure), bradycardia, and decreased respirations. The patient may also display a decreased level of consciousness, seizures, or both. These symptoms represent the Cushing's triad and require immediate intervention. Not remembering what happened, a sleeping patient who awakens in response to painful stimuli, and a blood pressure of 110/80 mm Hg. pulse of 78 beats/min, and respirations of 20 breaths/min do not necessarily indicate deterioration in the patient's condition. Text Reference - p. 1360

The nurse assesses a patient for signs of meningeal irritation and observes for nuchal rigidity. What indicates the presence of this sign of meningeal irritation? 1 Tonic spasms of the legs 2 Curling in a fetal position 3 Arching of the neck and back 4 Resistance to flexion of the neck

Answer: 4 Nuchal rigidity is a clinical manifestation of meningitis. During assessment, the patient will resist passive flexion of the neck by the health care provider. Tonic spasms of the legs, curling in a fetal position, and arching of the neck and back are not related to meningeal irritation . Text Reference - p. 1382

The nurse is reviewing the interventions prescribed by the health care provider for a patient with a basilar skull fracture. The nurse should collaborate with the health care provider about which intervention? 1 Apply soft cervical collar. 2 Avoid flexion of hip joints. 3 Keep head of bed elevated to 30° at all times. 4 Insert nasal gastric tube and connect to low, intermittent suction.

Answer: 4 Patients who need gastric decompression following a basilar skull fracture should have an oral gastric tube inserted. The nurse should collaborate with the health care provider about this intervention because of the risk of meningitis. An oral feeding is recommended, with placement of either an oral tube or nasogastric (NG) tube under fluoroscopy. The use of a soft cervical collar to maintain anatomical alignment, avoiding flexion of hip joints, and elevating the head of the bed are all measures to decrease intracranial pressure by promoting venous return. Text Reference - p. 1374

After learning about rehabilitation for a spinal cord tumor, which statement shows the patient understands what rehabilitation is and can do for him or her? 1 "I want to be rehabilitated for my daughter's wedding in two weeks." 2 "Rehabilitation will be more work done by me alone to try to get better." 3 "I will be able to do all my normal activities after I go through rehabilitation." 4 "With rehabilitation, I will be able to function at my highest level of wellness."

Answer: 4 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. Text Reference - p. 1480

A patient diagnosed with Guillain-Barré syndrome has a weak gag reflex. Which complication associated with a weak gag reflex should the nurse intervene for? 1 Severe vomiting 2 Difficulty breathing 3 Impaired taste sensations 4 Aspiration of food into the airways

Answer: 4 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. Text Reference - p. 1468

A patient is brought to the emergency room after a head injury and is at risk of developing increased intracranial pressure. Which is the most reliable indicator that the nurse should use for assessing the patient's neurological status? 1 Dim vision 2 Papilledema 3 Body temperature 4 Level of consciousness

Answer: 4 The level of consciousness is the most sensitive and reliable indicator of the patient's neurologic status. Dim vision can occur due to dysfunction of cranial nerves. Papilledema, which is an edematous optic disc seen on retinal examination, can be noted and is a nonspecific sign associated with persistent increases in intracranial pressure (ICP). A change in body temperature may also occur because increased ICP affects the hypothalamus.

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? 1 C1-3 2 C5-T6 3 T1-L2 4 Above T5

Answer: C1-3 Injury at C1-3 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-T6 causes decreased respiratory reserve. Injuries between T1-L2 may cause bladder retention. Injuries above T5 may manifest as paralytic ilieus. Text Reference - p. 1470

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. A Show sympathy towards the patient. B Explain the injury using written teaching material. C Encourage the patient to participate in care. D Encourage the patient to set daily goals. E Teach the patient what to expect during the rehabilitation period.

Answer: c, d, e Appropriate nursing actions include encouraging the patient to participate in care, encouraging the patient to set 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 Text Reference - p. 1483

A patient with increased intracranial pressure (ICP) will undergo lumbar puncture for cerebrospinal fluid (CSF) drainage. In which order are the necessary actions performed for intermittent CSF drainage? 1. Determine that the ICP is above the indicated level. 2. Open the ventriculostomy system at the indicated ICP. 3. Allow CSF to drain for 2 to 3 minutes. 4. Close the stopcock to return the ventriculostomy to a closed system.

Reading that the ICP is above the indicated level is the first step. If ICP is above the indicated level, opening the ventriculostomy system at the indicated ICP is the next step. Once the stopcock is opened, allowing CSF to drain for 2 to 3 minutes helps to relieve the pressure in the cranial vault. Closing the stopcock to return the ventriculostomy to a closed system is the final step. Text Reference - p. 1363

A patient with meningococcal meningitis is suspected to have a complication called Waterhouse-Friderichsen syndrome. Which possible findings would the nurse observe regarding this complication? Select all that apply. 1 Diplopia 2 Petechiae 3 Pulmonary effusion 4 Adrenal hemorrhage 5 Disseminated intravascular coagulation (DIC)

Answer 2, 4, 5 Waterhouse-Friderichsen syndrome is a complication of meningococcal meningitis, which is manifested by petechiae, adrenal hemorrhage, DIC, and circulatory collapse. Waterhourse-Friderichsen syndrome does not cause diplopia and pulmonary effusion.

A patient experienced head trauma in a car crash. There are many steps in the pathophysiology of the progression from injury to severe increased intracranial pressure (ICP) and death. In which order do the listed events occur? Put a comma and space between each answer choice (1, 2, 3, 4, etc.) Correct 1. Tissue edema from initial insult 2. Increased ICP 3. Compression of ventricles and blood vessels 4. Decreased cerebral blood flow 5. Increased ICP with brainstem compression 6. Increased ICP from increased blood volume

After initial insult to the brain, there is tissue edema, which causes an initial increase in ICP, then compression of ventricles and blood vessels, which decreases cerebral blood flow, thus decreasing O2 and causing death of brain cells. Edema occurs around this necrotic tissue and ICP is increased with compression of the brainstem and respiratory center, leading to accumulation of CO2. ICP is increased further from increased blood volume, which leads to death. Text Reference - p. 1359

A patient is reported to have a brain abscess in the occipital lobe. When assessing the patient, which symptoms would the nurse expect to find? Select all that apply. 1 Visual field defects 2 Headache and fever 3 Nausea and vomiting 4 Psychomotor seizures 5 Visual impairment and hallucinations

Answer: 2, 3, 5 Headache, fever, and nausea and vomiting are common symptoms of a brain abscess, and visual impairment and hallucinations can be seen in occipital abscess. Visual field defects and psychomotor seizures are seen in abscess of the temporal lobe. Text Reference - p. 1381

A patient with elevated intracranial pressure (ICP) is at risk for lower cerebral perfusion pressure (CPP) during suctioning. The nurse should maintain CPP above mm Hg to preserve cerebral perfusion. Record your answer as a whole number.

Answer: 60 Patients with elevated ICP are at risk for lower CPP during suctioning. CPP must be maintained above 60 mm Hg to preserve cerebral perfusion. Text Reference - p. 1357