Exam 3 Neuro-Spinal
The nurse is preparing a teaching tool to about herniated disks. Which nonpharmacologic therapy should the nurse include in in the tool? Low-phosphorus diet Leg-press exercises Meditation Weight loss
Weight loss
A patient is being admitted for recurrent seizure activity. What assessment data is most important for the nurse to obtain? Surgical history Occupational history Past seizure activity Menopause status
Past seizure activity
The shift charge nurse is reviewing charts for patients with traumatic brain injury (TBI). Which patient should the shift charge nurse identify as having an acceleration-deceleration injury? Patient with a gunshot wound to the head Patient whose head was struck by a metal object in a construction accident Patient who is a victim of violence whose head was punched repeatedly Patient whose head struck the dashboard of the vehicle in a high-speed crash
Patient whose head struck the dashboard of the vehicle in a high-speed crash
The nurse completes an assessment of a patient with a thoracic spinal cord injury (SCI). Which should the nurse identify as an appropriate outcome for this patient? Patient will resume independence with ambulation. Patient will demonstrate normal bladder and bowel patterns. Patient will have effective respirations without assistance. Patient will regain upper extremity functioning.
Patient will demonstrate normal bladder and bowel patterns.
A patient with spinal cord injury (SCI) will be immobile for an extended period of time. Which action should the nurse take to prevent the development of deep vein thrombosis (DVT)? Encouraging high-protein food choices Providing good skin care Performing passive range-of-motion exercises for the patient Padding hard surfaces such as bedrails
Performing passive range-of-motion exercises for the patient
Which is the most frequent cause of increased intracranial pressure (IICP)? Hemorrhage Tissue ischemia Abscesses Tumors
Tissue ischemia
For which purpose would a serum osmolality test be implemented for a patient with increased intracranial pressure? To indicate adequacy of serum protein levels To identify serum lactic acid levels To determine hydration status To assess serum pH
To determine hydration status
A patient with a spinal cord injury (SCI) is demonstrating signs of atelectasis. Which intervention should the nurse add to this patient's plan of care? Transfer out of bed to a chair daily Support extremities Complete passive range-of-motion every 4 hours Turn, deep breathe, and cough every 2 hours
Turn, deep breathe, and cough every 2 hours
A patient with a spinal cord injury (SCI) is having a 2-month follow-up evaluation. Which outcome should the nurse consider desirable? One very small wound on the sacrum Oxygen saturation of 92% Urine clear/pale yellow in color Two bowel movements per week
Urine clear/pale yellow in color
The nurse is preparing a plan of care for a patient recovering from an injury that has caused increased intracranial pressure (IICP). Which action should the nurse plan to include to help reduce cerebral edema? Applying a cooling blanket Regulating the infusion of a proton pump inhibitor Administering prescribed loop diruetic Raising the head of the bed 30°
Administering prescribed loop diruetic
A patient with a traumatic brain injury (TBI) is intubated and placed on mechanical ventilation. Which information should the nurse use to evaluate the effectiveness of this respiratory intervention? Glasgow Coma Scale score Cranial nerve function Motor and sensory function Arterial blood gas results
Arterial blood gas results
The nurse is caring for a patient poststroke. Which action is most important prior to feeding the patient? Sitting the patient upright Assessing the results of the swallowing studies Ordering a soft or pureed diet Placing the food in the unaffected side of the mouth
Assessing the results of the swallowing studies
A patient is experiencing fever and chills, severe headache, and nausea and vomiting. For which health problem should the nurse expect vancomycin to be prescribed for this patient? Bacterial meningitis Seizure disorder Tetanus Brain abscess
Bacterial meningitis
The nurse is caring for a patient who was diagnosed with thrombotic stroke 4 hours ago. The family asks about the plan for treatment. Which statement should be included in the teaching to the family about the treatment plan? "Because the patient has a history of stroke, IV tPA will be administered." "Drugs that break up clots, such as tPA, must be given within 3 to 4.5 hours of symptom onset." "IV heparin will be started immediately after the tPA administration to prevent stroke recurrence." "Heparin is given initially followed by an infusion of drugs such as tPA to finish breaking up the clot."
"Drugs that break up clots, such as tPA, must be given within 3 to 4.5 hours of symptom onset."
The nurse is caring for an older woman being admitted for recurrent seizure activity. When conducting the health history, which question is most appropriate? "What did you do for work?" "Have you ever had a seizure before?" "When did you start menopause?" "Have you had any recent surgery?"
"Have you ever had a seizure before?"
A patient is being treated for a cervical hyperextension injury. In which way should the nurse explain this injury? "Hyperextension is backward bending of the neck or spine beyond normal limits." "Hyperextension is vertical force applied to the spinal column." "Hyperextension is forward bending of the neck or spine beyond normal limits." "Hyperextension is lateral flexion or twisting of the head and neck.
"Hyperextension is backward bending of the neck or spine beyond normal limits."
A patient is diagnosed with stroke at the right anterior cerebral artery. The nurse asks the patient's daughter, "What changes have you noticed in your mother?" Which response by the daughter would be consistent with the patient's diagnosis? "She doesn't seem to see the food on her plate." "I have to make all the decisions for my mother." "I have to really watch her when she's eating." "She has difficulty walking."
"I have to make all the decisions for my mother."
The nurse is providing discharge teaching to a patient with a spinal cord injury (SCI) who is at risk for autonomic dysreflexia. For which patient statement should the nurse provide additional teaching? "I need to check my feet regularly for ingrown toenails." "I cannot become overstimulated during sex." "I should not wear clothing that is too tight." "I should restrict fluid and eat a low-fiber diet."
"I should restrict fluid and eat a low-fiber diet."
A patient with partial paralysis is able to transfer to and from a wheelchair with assistance and also perform most self-care activities. For which patient statement should the nurse refer the patient to home care? "My bathroom is on the second floor." "My spouse can leave things on the counter for me to reach." "My wheelchair will fit through the bathroom door but not the laundry room door." "There are no steps leading to my front door."
"My bathroom is on the second floor."
A patient with obesity is experiencing increasing back pain. Which should the nurse recommend to this patient? "Regular exercise will help to strengthen your back." "You need to lose weight." "You might need to get used to the pain." "You should exercise to lose that weight."
"Regular exercise will help to strengthen your back."
A patient asks what causes sciatica. Which response should the nurse make? "Sciatica is caused by a leakage of spinal fluid onto the sciatic nerve." "Sciatica is caused by irritation or compression of the sciatic nerve." "Sciatica is caused by meningitis." "Sciatica is caused by a laceration of the sciatic nerve."
"Sciatica is caused by irritation or compression of the sciatic nerve."
The nurse is caring for a patient who experienced a seizure. The patient indicates that they were watching television when the seizure occurred and asks why they had the seizure. Which response from the nurse indicates a correct understanding of the cause of seizures? "Seizures are caused by having a fever." "Seizures are caused by low blood sugar." "Seizures are often caused by watching television." "Seizures are caused by abnormal electrical impulses in the brain."
"Seizures are caused by abnormal electrical impulses in the brain."
A patient with an incomplete lumbar spinal cord injury had a physical therapy visit for consultation. Which patient statement should indicate the need for additional teaching about rehabilitation? "The rehab team's goal is for me to function as independently as possible." "They are sending me to rehab so that I can finally get some rest!" "They are going to do gait training to strengthen my muscles." "They are going to help me to get along at home."
"They are sending me to rehab so that I can finally get some rest!"
A patient with a cervical fracture is prescribed a support device. In which way should the nurse describe this device to the patient? "This traction will involve rods and screws that are placed internally." "The device requires small bone grafts to maintain alignment." "This device can be used intermittently to control pain." "This halo fixation device is used to stabilize the cervical region."
"This halo fixation device is used to stabilize the cervical region."
The nurse caring for a patient who has been intubated and placed on a ventilator for increased intracranial pressure (IICP) is describing the patient's treatment to a family member. Which statement by the nurse is correct? "The pressure in your dad's brain is low, and the ventilator will help him breathe." "Your dad is very ill and may not recover so the machine is doing the breathing for him." "The tube in your dad's airway provides extra carbon dioxide to decrease the pressure in his brain." "This treatment is for airway protection and respiratory management."
"This treatment is for airway protection and respiratory management."
The nurse is caring for a patient with a diagnosis of increased intracranial pressure (IICP). The unlicensed assistive personnel (UAP) asks, "Are special precautions to be taken when caring for a patient with IICP?" Which response by the nurse is accurate? "No, there are no special precautions." "Yes, keep the bed flat." "Yes, raise the pads and bedrails." "Yes, be sure to leave the TV on at all times."
"Yes, raise the pads and bedrails."
The nurse is preparing a presentation to community members on risk factors associated with back pain. Which patient should the nurse identify as being most at risk for herniated disks? A 45-year-old man who works for a shipping company A normal-weight 18-year-old man who swims competitively A short-statured 25-year-old woman who walks regularly A 35-year-old woman with no family history of bone disorders
A 45-year-old man who works for a shipping company
The nurse is teaching a patient about a carotid endarterectomy. Which explanation should the nurse use to describe the procedure? A carotid endarterectomy removes atherosclerotic plaque from the carotid arteries. A carotid endarterectomy uses a stent to enlarge the diameter of the carotid artery. A carotid endarterectomy reroutes blood flow through cerebral tissue. A carotid endarterectomy shoots pulses of water through the artery to widen the blood vessel.
A carotid endarterectomy removes atherosclerotic plaque from the carotid arteries.
A nurse is completing an assessment of a client who has increased intracranial pressure (ICP). Which of the following are expected findings? (SATA) A. Disoriented to time and place B. Restlessness and irritability C. Unequal pupils D. ICP 15 mm Hg E. Headache
A, B, C, and E are correct. D: ICP of 15 mm Hg is within expected reference range.
A nurse is caring for a client who is having surgery for the removal of an encapsulated acoustic tumor. Which of the following potential complications should the nurse monitor for postoperatively? (SATA) A. Increased intracranial pressure B. Hemorrhagic shock C. Hydrocephalus D. Hypoglycemia E. Seizures
A, C, and E are correct. B: Hypovolemic shock, not hemorrhagic shock D: Alteration in glucose metabolism is not usually a post op concern after this surgery.
A nurse is reviewing a prescription for dexamethasone with a client who has an expanding brain tumor. Which of the following are appropriate statements by the nurse? (SATA) A. "It is given to reduce swelling of the brain." B. "You will need to monitor for low blood sugar." C. "You might notice weight gain." D. "Tumor growth will be delayed." E. "It can cause you to retain fluids."
A, C, and E are correct. Dexamethasone is a common steroid prescribed to reduce cerebral edema. C and E are adverse reactions of dexamethasone. B: Monitor for HIGH blood sugar D: Dexamethasone does NOT affect tumor growth. It is given to prevent cerebral edema.
A patient with a traumatic brain injury is diagnosed as being brain dead. Which assessment finding supports this diagnosis? Awareness of environment but unable to communicate Absence of spontaneous respirations Complete unawareness of self Neck extended and the jaw clenched
Absence of spontaneous respirations
A nurse is caring for a client who has just undergone a craniotomy for a supratentorial tumor and has a respiratory rate of 12. Which of the following postoperative prescriptions should the nurse clarify with the provider? A. Dexamethasone 30 mg IV bolus BID B. Morphine sulfate 2 mg IV bolus PRN every 2 hr for pain C. Odansetron 4 mg IV bolus PRN every 4 to 6 hr for nausea D. Phenytoin 100 mg IV bolus TID
B is correct. Can cause further respiratory depression. A, C, and D have no depressant effects.
A nurse is caring for a client who has a benign brain tumor. The client asks the nurse if this same type of tumor can occur in other areas of the body. Which of the following responses should the nurse make? A. "It can spread to breasts and kidneys." B."It can develop in your gastrointestinal tract." C. "It is limited to brain tissue." D. "It probably started in another area of your body and spread to your brain."
C is correct. Brain tumors do NOT metastasize since they develop from the meninges and cranial nerves. A and B: Metastases of brain tumors do no occur D: Benign brain tumors develop from the meninges or cranial nerves and are not secondary to other types of tumors.
A patient is prescribed a halo fixation device. For which type of injury should this device be used? Cervical Sacral Lumbar Thoracic
Cervical
The nurse is caring for a patient with Creutzfeldt-Jakob disease (CJD). Which should the nurse expect to be prescribed for this patient? Corticosteroids Comfort measures Physical therapy Antibiotics
Comfort measures
A patient with a spinal cord injury (SCI) is able to perform most self-care activities, including getting to and from the wheelchair with assistance. Which action should the nurse take when the patient reports having to wait until a spouse returns home from work to use the bathroom? Instruct on the use of a urinary catheter during the day Complete a referral to home care Suggest restricting fluids during the day Recommend changing the bathroom to accommodate the patient's needs
Complete a referral to home care
A patient with fractures at C5 and C6 is experiencing spinal swelling. Which medication should the nurse anticipate being prescribed for this patient? Corticosteroid Antispasmodic Vasopressor Antiemetic
Corticosteroid
A nurse is reviewing the health record of a client who has a malignant brain tumor and notes the client has a positive Romberg sign. Which of the following actions should the nurse take to assess for this finding? A. Stroke the lateral aspect of the sole of the foot. B. Ask the client to blink both eyes. C. Observe for facial drooping. D. Have the client stand erect with eyes closed.
D is correct. A positive Romberg sign is indicated when a client loses their balance while attempting to stand erect with their eyes closed. A: Babinski sign B and C: Assesses cranial nerve function
An adolescent patient with cervical spinal cord injury is being discharged to home. Which intervention should the nurse provide to facilitate the discharge? Providing information about group home options Discussing ways to make the home environment accessible Providing information about home schooling Discussing the patient's prognosis and expected lifespan with the parents
Discussing ways to make the home environment accessible
The nurse is assessing a patient with a spinal cord injury (SCI). Which should the nurse do after learning that the patient's urine is clear and yellow in color? Assess for other symptoms of a urinary tract infection. Document as a desireable outcome. Report to the healthcare provider. Instruct to increase the intake of oral fluids.
Document as a desireable outcome.
The nurse is caring for a patient with a suspected seizure disorder. Which diagnostic test should the nurse anticipate to be ordered? Electromyogram (EMG) Electrocardiogram (ECG) Electroencephalogram (EEG) Erythrocyte sedimentation rate (ESR)
Electroencephalogram (EEG)
Upon entering the room of a patient hospitalized for increased intracranial pressure (IICP) secondary to head trauma from a motor vehicle crash, the nurse notes that the patient has been placed in a supine position by the family. What is the nurse's initial response to this situation? Maintain the current patient position and reinforce with the family the need to remain in this position. Ask the family if they placed the patient in this position or if the patient did so independently. Turn the patient to the left side, using pillows to align the body properly. Elevate the head of the bed to 30o and explain to the family the importance of this position.
Elevate the head of the bed to 30o and explain to the family the importance of this position.
A patient is diagnosed with a metastatic spinal tumor. Which should the nurse identify as a goal of care for this patient? Maximize oxygenation Enhance perfusion Promote independence Enhance quality of life
Enhance quality of life
The nurse is completing a health history for a patient with a suspected neurologic issue. Which alteration(s) should the nurse observe for to ensure that any deviations from normal are addressed? Emotional response to questions asked Patient willingness to answer questions Facial movements, speech patterns, and alertness Level of eye contact with nurse during assessment
Facial movements, speech patterns, and alertness
The nurse is caring for a patient admitted for a postopioid overdose who has suspected brain death. Which criterion would be most appropriate for the healthcare provider to independently use to establish the absence of brain activity for this patient? Absent ocular responses to head turning Fixed and dilated pupils No spontaneous respiration Flat electroencephalogram (EEG)
Flat electroencephalogram (EEG)
A patient is experiencing severe left-sided back pain starting near their tail bone and radiating down the leg, accompanied by numbness and tingling in the left calf and heel. Which pathologic process should the nurse suspect is causing the patient's symptoms? Herniated disc in the L4-L5 region Herniated disc in the L5-S1 region Cervical herniated disc Scoliosis
Herniated disc in the L5-S1 region
A patient is 40 lbs. overweight. For which neurologic health problem should the patient consider losing weight? Meningitis Seizure disorder Spinal cord injury Herniated disk
Herniated disk
A patient is being treated for a whiplash. Which should the nurse expect to have occurred to this patient's vertebral column? Transection of the spinal cord Compression Hyperextension Hyperflexion
Hyperextension
A patient experienced an ischemic stroke in the right anterior cerebral artery. Which clinical manifestation should the nurse expect to find? Problems with gait Homonymous hemianopia Inability to make decisions Dysphagia
Inability to make decisions
A patient is being evaluated for cauda equina syndrome. Which complication should the nurse expect to assess in this patient? Loss of bladder control Pain radiating up back Numbness isolated to toes Upper lumbar pain
Loss of bladder control
A patient is transported to the emergency department following a fall from a roof. Which test should the nurse expect to be prescribed to determine soft tissue damage surrounding the spine? Lumbar puncture MRI of the spine Vertebral angiogram Spinal x-ray
MRI of the spine
The nurse is caring for a patient with bacterial meningitis. For which reason should the nurse monitor the patient's output and daily weights? Reduce the risk of infection Promote nutritional status Enhance healing Maintain hydration
Maintain hydration
A patient with an alteration in intracranial regulation is exhibiting status epilepticus. Which intervention is the priority for the nurse? Establishing an IV line Managing the airway Delivering glucose Administering antiseizure medication
Managing the airway
The nurse is caring for a patient who was transported to the emergency department after having a seizure. Which nursing actions are critical during the postictal period of seizure activity? Performing neurologic checks and suctioning every 15 minutes Ensuring safety and drawing blood for ordered tests Monitoring vital signs, inserting an intravenous line, and performing cardiopulmonary resuscitation Monitoring vital signs, performing neurological checks, and ensuring safety
Monitoring vital signs, performing neurological checks, and ensuring safety
The nurse is caring for a patient with a herniated disc. Which should the nurse recognize as the cause of the pain? Disc herniation Nerve compression Fascitis Myelitis
Nerve compression
The nurse is reviewing the history of a patient admitted for an altered level of consciousness (LOC). Which systemic condition noted in the patient's history should the nurse consider to be a contributing factor to this alteration? Exposure to heavy metals Demyelinating disorders Poorly controlled diabetes Increased intracranial pressure
Poorly controlled diabetes
The nurse is planning care for a patient with a spinal cord injury (SCI). For which reason should the nurse assist the patient to turn, deep-breathe, and cough at least every 2 hours? Maintain joint function Reduce the development of a pressure injury Prevent atelectasis Prevent muscle atrophy
Prevent atelectasis
A patient with fractures of L4 and L5 has no leg sensation, is incontinent of bowel and bladder, has a body temperature of 98.0°F (36.7°C), a heart rate of 58 beats/min, and blood pressure of 96/60 mmHg. Which health problem should the nurse suspect the patient is experiencing? Spinal shock Incomplete transection of the spinal cord Autonomic dysreflexia Tetraplegia
Spinal shock
A nurse is explaining the steps of the ischemic cascade that occurs during a stroke. Which should the nurse include as the first step? Leukocytes enter the area of damage, causing more damage to the brain. The blood supply is cut off to part of the brain. Brain cells are damaged when the cell membranes allow water to enter the cells. The damaged cells release chemicals affecting other cells around them.
The blood supply is cut off to part of the brain.
A patient is admitted with an injury in the cervical region of the spinal cord. For which reason should the nurse monitor this patient's respiratory functioning? The muscles required for breathing might not function. Hemorrhage in the spinal cord will interfere with nerve transmission to the lungs. Bone fragments from the damaged vertebrae can lodge in the trachea and bronchi. The patient is at high risk of aspiration caused by pressure on the esophagus from the injury.
The muscles required for breathing might not function.
The nurse is completing a health history for a patient who is suspected of having an acute stroke. Which assessment finding should the nurse immediately report to the healthcare provider? The onset of symptoms was 2.5 hours ago. The patient has never had a stroke before. The patient has a 20-year history of smoking two packs of cigarettes per day. The patient's father died of a stroke.
The onset of symptoms was 2.5 hours ago.
A patient is preparing to go home following a recent stroke. Which behavior indicates that the patient has met nursing care plan goals? The patient has experienced minimal complications from reduced mobility and dysphagia. The patient's family is at the bedside daily assisting the patient with all activities of daily living. The patient is sipping water with meals to help with swallowing. The patient is participating in range of motion exercises each day.
The patient has experienced minimal complications from reduced mobility and dysphagia.
The nurse is caring for a patient immediately after a seizure. Which assessment finding should the nurse expect? The patient is unconscious. The patient is experiencing muscular contractions. The patient is sleepy but arousable. The patient is cyanotic.
The patient is sleepy but arousable.
The nurse is caring for a patient who is suspected of having an acute stroke. Which is the most important information to gather from the family? Smoking history Patient history of stroke Time of onset of symptoms Family history of stroke
Time of onset of symptoms