PRACTICE Q'S - SCI AND NS DISORDERS

For a 65-year-old female patient who has lived with a T1 spinal cord injury for 20 years, which health teaching information should you emphasize? A. A mammogram is needed every year. B. Bladder function tends to improve with age. C. Heart disease is not common in persons with spinal cord injury. D. As a person ages, the need to change body position is less important.

A. A mammogram is needed every year. Health promotion and screening are important for the older patient with a spinal cord injury. Older adult women with spinal cord injuries should perform monthly breast examinations and yearly mammograms

What is the best method to assess a patient with trigeminal neuralgia (tic douloureux)? A. Ask the patient what the triggering factors are. B. Have the patient open and close the jaw while palpating the mandible. C. Instruct the patient to touch the examiner's finger and then the patient's nose. D. Look at the optic disk with an ophthalmoscope

A. Ask the patient what the triggering factors are. The main symptom is spasms of severe, unilateral facial pain. Palpating the face may trigger a painful episode; touch is a common trigger. The other options do not reveal information about the trigeminal nerve effect.

Which is most important to respond to in a patient presenting with a T3 spinal injury? A. Blood pressure of 88/60 mm Hg, pulse of 56 beats/minute B. Deep tendon reflexes of 1+, muscle strength of 1+ C. Pain rated at 9 D. Warm, dry skin

A. Blood pressure of 88/60 mm Hg, pulse of 56 beats/minute Neurogenic shock is a loss of vasomotor tone caused by injury, and it is characterized by hypotension and bradycardia. The loss of sympathetic nervous system innervations causes peripheral vasodilation, venous pooling, and a decreased cardiac output. The other options can be expected findings and are not as significant. Patients in neurogenic shock have pink and dry skin, instead of cold and clammy, but this sign is not as important as the vital signs.

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

A. Bradycardia Neurogenic shock results from loss of vasomotor tone caused by injury and is characterized by hypotension and bradycardia. Loss of sympathetic innervation causes peripheral vasodilation, venous pooling, and a decreased cardiac output.

What should the patient with Bell's palsy be cautioned against? A. Cornea dryness B. Driving while experiencing diplopia C. Sudden movement of the head when bending over D. Contamination from the affected eye to the other eye

A. Cornea dryness With Bell's palsy, the eyelid on the affected side often does not close tightly. Eye drops are used during the daytime, and patches are worn at night. The other options are not related to Bell's palsy.

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

A. Headache and rising blood pressure Among the manifestations of autonomic dysreflexia are hypertension (up to 300 mm Hg systolic) and throbbing headache. Respiratory manifestations, decreased level of consciousness, and gastrointestinal manifestations are not characteristic.

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

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

Which intervention should you perform in the acute care of a patient with autonomic dysreflexia? A. Urinary catheterization B. Administration of benzodiazepines C. Suctioning of the patient's upper airway D. Placement of the patient in the Trendelenburg position

A. Urinary catheterization Because the most common cause of autonomic dysreflexia is bladder irritation, immediate catheterization to relieve bladder distention may be necessary. The patient should be positioned upright. Benzodiazepines are contraindicated, and suctioning is likely unnecessary.

Which is a classic presentation of Guillain-Barré syndrome? A. Acute change in level of consciousness B. Ascending, symmetric paralysis C. Acute onset of paralysis in lower extremities D. Paresthesias in legs starting with feet and radiating to groin area

B. Ascending, symmetric paralysis Guillain-Barré syndrome is an acute, rapidly progressing polyneuritis with ascending, symmetric paralysis. The other options are not related to Guillain-Barré syndrome.

What is a common treatment for trigeminal neuralgia? A. Warm, moist compressions B. Carbamazepine (Tegretol) C. Ice packs applied intermittently D. Vitamin D

B. Carbamazepine (Tegretol) Carbamazepine (Tegretol) or oxcarbazepine (Trileptal) is the usual first-line therapy for trigeminal neuralgia. By acting on sodium channels, these drugs lengthen the time needed for neuron repolarization and decrease neuron firing. Some patients take megavitamins as an adjunct therapy. Temperature extremes are often a trigger for painful episodes.

The patient is diagnosed with Guillain-Barré syndrome and admitted to the inpatient unit from the emergency department. What is the most important nursing observation? A. Urine output B. Depth of respiration C. Bowel sounds D. Lower extremity strength

B. Depth of respiration The most serious complication is paralysis progressing to the nerves that innervate the thoracic area and causing respiratory failure. You must constantly monitor the respiratory system by checking respiratory rate and depth, forced vital capacity, and negative inspiratory force. The other options may be affected, but respiratory function is most important.

What are the goals of rehabilitation for the patient with an injury at the C6 level (select all that apply)? A. Stand erect with leg brace B. Feed self with hand devices C. Drive an electric wheelchair D. Assist with transfer activities E. Drive adapted van from wheel chair

B. Feed self with hand devices C. Drive an electric wheelchair D. Assist with transfer activities E. Drive adapted van from wheel chair Rehabilitation goals for a patient with a spinal cord injury at the C6 level include ability to assist with transfer and perform some self-care; feed self with hand devices; push wheelchair on smooth, flat surface; drive adapted van from wheelchair; independent computer use with adaptive equipment; and needing attendant care only for 6 hours per day.

You are caring for a patient admitted with a spinal cord injury after a motor vehicle accident. The patient exhibits a complete loss of motor, sensory, and reflex activity below the injury level. What is this condition? A. Central cord syndrome B. Spinal shock syndrome C. Anterior cord syndrome D. Brown-Séquard syndrome

B. Spinal shock syndrome 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 loss of reflexes. Brown-Séquard syndrome is characterized by ipsilateral loss of motor function and contralateral loss of sensory function.

You suspect Bell's palsy in which patient? A. Unilateral facial droop with contralateral extremity weakness B. Sudden onset one-sided facial weakness with ear pain and vesicles C. Sharp, knife-like facial pain when eating hot or cold foods D. Inability to shrug the shoulders against resistance

B. Sudden onset one-sided facial weakness with ear pain and vesicles Bell's palsy is an acute, peripheral facial paresis of unknown cause without systemic effects. Facial droop is found in stroke. Sharp facial pain occurs with trigeminal neuralgia. An inability to shrug the shoulders describes pathology of cranial nerve XI.

One month after a spinal cord injury, which finding is most important for you to monitor? A. Bladder scan indicates 100 mL. B. The left calf is 5 cm larger than the right calf. C. The heel has a reddened, nonblanchable area. D. Reflux bowel emptying.

B. The left calf is 5 cm larger than the right calf. Deep vein thrombosis is a common problem accompanying spinal cord injury during the first 3 months. Pulmonary embolism is one of the leading causes of death. Common signs and symptoms are absent. Assessment includes Doppler examination and measurement of leg girth. The other options are not as urgent to deal with as potential deep vein thrombosis.

What is essential teaching in treating a patient with Bell's palsy? A. Perform eye exercises to maintain strength. B. Obtain a herpes simplex virus (HSV) immunization. C. Do not abruptly stop the corticosteroids. D. Vigorously massage the area to promote circulation.

C. Do not abruptly stop the corticosteroids. Corticosteroids are usually started immediately. After they are no longer necessary, they should be tapered. Other treatment includes moist heat, gentle massage, and antiviral medications, such as acyclovir (Zovirax). Eye exercises are not indicated. HSV is identified in 70% of infections, but immunization is not beneficial at this point. Antiviral drugs may be used. Vigorous massage can break down tissues, but gentle upward massage has psychologic benefits.

What is characteristic of trigeminal neuralgia (tic douloureux)? A. Unilateral facial drooping B. Inability to hear whispered speech C. One-sided facial stabbing pain D. Attacks of severe dizziness

C. One-sided facial stabbing pain Trigeminal neuralgia is usually unilateral, severe, brief, stabbing, recurrent episodes of pain in the distribution of the trigeminal nerve. Unilateral facial drooping is found in Bell's palsy or facial nerve pathology (cranial nerve [CN] VII). Inability to hear indicates pathology of the acoustic nerve (CN VIII). Attacks of severe dizziness do not occur in trigeminal neuralgia.

What is most important action for a patient who has a suspected cervical spinal injury? A. Apply a soft foam cervical collar. B. Perform a neurologic check. C. Place the patient on a firm surface. D. Assess function of cranial nerves IX and X.

C. Place the patient on a firm surface. A patient with a suspected cervical spine injury should be immobilized with a hard collar and placed on a firm surface. This takes priority over any further assessment. A soft foam collar does not provide immobilization.

You are providing care for a patient who has been diagnosed with Guillain-Barré syndrome. Which assessment should you prioritize? A. Pain assessment B. Glasgow Coma Scale C. Respiratory assessment D. Musculoskeletal assessment

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

What is the primary goal of nursing care for the patient with Guillain-Barré syndrome? A. Assist the patient to adapt to their lifelong paralysis. B. Teach the patient to use a communication board. C. Support body systems until the patient recovers. D. Place the patient in contact isolation to prevent spread of the condition.

C. Support body systems until the patient recovers. The objective of therapy is to support body systems until the patient recovers. Respiratory failure and infection are serious threats. Most patients recover eventually. Depending on the progression of the disease, the patient may be incapable of communicating.

A patient with a C7 spinal cord injury undergoing rehabilitation tells you he must have the flu because he has a bad headache and nausea. What is your initial action? A. Call the physician. B. Check the patient's temperature. C. Take the patient's blood pressure. D. Elevate the head of the bed to 90 degrees.

C. Take the patient's blood pressure. Autonomic dysreflexia is a massive, uncompensated cardiovascular reaction mediated by the sympathetic nervous system. Manifestations include hypertension (up to 300 mm Hg systolic), throbbing headache, marked diaphoresis above the level of the lesion, bradycardia (30 to 40 beats/minute), piloerection, flushing of the skin above the level of the lesion, blurred vision or spots in the visual fields, nasal congestion, anxiety, and nausea. It is important to measure blood pressure when a patient with a spinal cord injury complains of a headache.

What is a predominant causative trigger for the painful episodes in trigeminal neuralgia? A. Staphylococcus aureus cellulitis B. Misaligned bite of molar teeth C. Direct trauma to transmandibular joint D. Touching along the lower jaw

D. Touching along the lower jaw Touch and tickle predominate as causative triggers. Others include chewing, tooth brushing, hot or cold blast of air on the face, washing the face, yawning, or talking. The other options are not significant causative factors.

When planning care for a patient with a C5 spinal cord injury, which nursing diagnosis is the highest priority? A. Impaired tissue integrity due to paralysis B. Impaired urinary elimination due to quadriplegia C. Ineffective coping due to the extent of trauma D. Ineffective airway clearance due to high cervical spinal cord injury

D. Ineffective airway clearance due to high cervical spinal cord injury Maintaining a patent airway is the most important goal for a patient with a high cervical fracture. Although all of these options are appropriate nursing diagnoses for a patient with a spinal cord injury, respiratory needs are always the highest priority. Remember the ABCs.

A patient is admitted to the intensive care unit (ICU) with a C7 spinal cord injury and diagnosed with Brown-Séquard syndrome. What would you most likely find on physical examination? A. Upper extremity weakness only B. Complete motor and sensory loss below C7 C. Loss of position sense and vibration in both lower extremities D. Ipsilateral motor loss and contralateral sensory loss below C7

D. Ipsilateral motor loss and contralateral sensory loss below C7 Brown-Séquard syndrome is a result of damage to one half of the spinal cord. This syndrome is characterized by a loss of motor function and position and vibratory sense, as well as vasomotor paralysis on the same side (ipsilateral) as the lesion. The opposite (contralateral) side has loss of pain and temperature sensation below the level of the lesion.

A patient is admitted to the hospital with a C4 spinal cord injury after a motorcycle collision. The patient's blood pressure is 83/49 mm Hg and pulse is 39 beats/minute. He remains orally intubated. What is the cause of this pathophysiologic response? A. Increased vasomotor tone after the injury B. A temporary loss of sensation and flaccid paralysis below the level of injury C. Loss of parasympathetic nervous system innervation resulting in vasoconstriction D. Loss of sympathetic nervous system innervation resulting in peripheral vasodilation

D. Loss of sympathetic nervous system innervation resulting in peripheral vasodilation eurogenic shock results from loss of vasomotor tone caused by injury, and it is characterized by hypotension and bradycardia. Loss of sympathetic nervous system innervation causes peripheral vasodilation, venous pooling, and a decreased cardiac output. These effects usually are associated with a cervical or high thoracic injury (T6 or higher).

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

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

Which patient should be assigned to the experienced registered nurse on a neurologic floor? A. Patient with trigeminal neuralgia reporting facial pain rated at 10 B. Patient with Bell's palsy with unilateral facial droop C. Patient after surgical removal of a spinal cord tumor who is scheduled for discharge tomorrow D. Patient with traumatic injury to the cervical spinal cord who was admitted today from the emergency department

D. Patient with traumatic injury to the cervical spinal cord who was admitted today from the emergency department The patient with the cervical spinal cord injury is potentially the most unstable and needs an experienced, professional nurse.

You are caring for a patient admitted 1 week earlier with an acute spinal cord injury. Which assessment finding alerts you to the presence of autonomic dysreflexia? A. Tachycardia B. Hypotension C. Hot, dry skin D. Throbbing headache

D. Throbbing headache Autonomic dysreflexia is related to reflex stimulation of the sympathetic nervous system, which is reflected by hypertension, bradycardia, throbbing headache, and diaphoresis.

The patient arrives in the emergency department from a motor vehicle accident, during which the car ran into a tree. The patient was not wearing a seat belt, and the windshield is shattered. What action is most important for you to do? A. Determine if the patient lost consciousness. B. Assess the Glasgow Coma Scale (GCS) score. C. Obtain a set of vital signs. D. Use a logroll technique when moving the patient.

D. Use a logroll technique when moving the patient. When the head hits the windshield with enough force to shatter it, you must assume neck or cervical spine trauma occurred and you need to maintain spinal precautions. This includes moving the patient in alignment as a unit or using a logroll technique during transfers. The other options are important and are done after spinal precautions are applied.

What is the most common cause of Guillain-Barré syndrome? A. Parasite infestation causing demyelinization. B. Brain neuron damage from plaques. C. Systemic sepsis from a bacterial infection. D. Viral infection or immunization.

D. Viral infection or immunization. The syndrome is often preceded by immune system stimulation by a viral infection, trauma, surgery, viral immunization, or human immunodeficiency virus (HIV). The other options are not related to Guillain-Barré syndrome.

The nursing instructor asks a nursing student to compare and contrast Bell's palsy and trigeminal neuralgia. Which statement by the nursing student is correct? a. "Difficulty chewing may occur in both disorders." b. "Both are disorders of the autonomic nervous system." c. "Facial twitching occurs in both disorders." d. "Both disorders are caused by the herpes simplex virus, which inflames and irritates cranial nerve V."

a. "Difficulty chewing may occur in both disorders." Both Bell's palsy and trigeminal neuralgia can affect cranial nerve V, which affects facial expressions and chewing. Both are disorders of the cranial nerves. Facial twitching can be a sign of trigeminal neuralgia, whereas Bell's palsy causes a unilateral facial paralysis. Bell's palsy is caused by the herpes simplex virus, unlike trigeminal neuralgia, which is thought to be caused by excessive firing of irritated nerve fibers in the trigeminal nerve.

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

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

After teaching a client with a spinal cord injury, the nurse assesses the client's understanding. Which client statement indicates a correct understanding of how to prevent respiratory problems at home? a. "I'll use my incentive spirometer every 2 hours while I'm awake." b. "I'll drink thinned fluids to prevent choking." c. "I'll take cough medicine to prevent excessive coughing." d. "I'll position myself on my right side so I don't aspirate."

a. "I'll use my incentive spirometer every 2 hours while I'm awake." Often, the person with a spinal cord injury will have weak intercostal muscles and is at higher risk for developing atelectasis and stasis pneumonia. Using an incentive spirometer every 2 hours helps the client expand the lungs more fully and prevents atelectasis. Clients should drink fluids that they can tolerate; usually thick fluids are easier to tolerate. The client should be encouraged to cough and clear secretions. Clients should be placed in high-Fowler's position to prevent aspiration.

A client with trigeminal neuralgia is admitted for a percutaneous stereotactic rhizotomy in the morning. The client currently reports pain. What does the nurse do next? a. Administers pain medication as requested b. Ensures that the client has nothing by mouth (NPO) c. Ensures that the preoperative laboratory work is complete d. Performs a preoperative assessment

a. Administers pain medication as requested Administers pain medication as requested Addressing the client's pain is the priority nursing intervention because pain is the main symptom of trigeminal neuralgia. This client is not required to be NPO until after midnight. Percutaneous stereotactic rhizotomy can be performed in an ambulatory care setting under general anesthesia, which would not require preoperative testing (except clotting time if the client were on anticoagulant therapy). A preoperative assessment can be performed after the client's pain has been addressed.

A patient is diagnosed with trigeminal neuralgia. Which therapy is the first-line choice for this patient? a. Antiepileptic such as carbamazepine (Tegretol). b. Muscle relaxant such as baclofen (Loresal) c. Percutanous stereotactic rhizotomy (PSR) d. Microvascular decompression

a. Antiepileptic such as carbamazepine (Tegretol).

The patient with GBS is at risk for aspiration. Which precautions must the nurse initiate to prevent aspiration? (Select all that apply.) a. Elevate the head of the bed at least 45 degrees. b. Have patient assessed for dysphagia before administering oral fluids or medications. c. Teach the patient coughing and deep-breathing exercises. d. Have suctioning equipment available at the bedside. e. Turn the patient from side to side at least every 2 hours.

a. Elevate the head of the bed at least 45 degrees. b. Have patient assessed for dysphagia before administering oral fluids or medications. d. Have suctioning equipment available at the bedside.

A nurse assesses a client who experienced a spinal cord injury at the T5 level 12 hours ago. Which manifestations should the nurse correlate with neurogenic shock? (Select all that apply.) a. Heart rate of 34 beats/min b. Blood pressure of 185/65 mm Hg c. Urine output less than 30 mL/hr d. Decreased level of consciousness e. Increased oxygen saturation

a. Heart rate of 34 beats/min c. Urine output less than 30 mL/hr d. Decreased level of consciousness Neurogenic shock with acute spinal cord injury manifests with decreased oxygen saturation, symptomatic bradycardia, decreased level of consciousness, decreased urine output, and hypotension.

What is the priority expected outcome in a patient with GBS? a. Maintain airway patency and gas exchange. b. Promote communication. c. Manage pain. d. Prevent complications of immobility.

a. Maintain airway patency and gas exchange.

Which strategies will the nurse teach a patient with Bell's palsy to use in managing pain and paralysis? (Select all that apply.) a. Massage b. Opioid pain medications c. Application of warm, moist heat d. Chew on the affected side of the mouth e. Facial exercises

a. Massage c. Application of warm, moist heat e. Facial exercises

What is the priority in caring for a patient with trigeminal neuralgia? a. Pain management b. Promoting communication c. Improving mobility d. Providing psychosocial support

a. Pain management

When caring for a patient who experienced a T2 spinal cord transection 24 hours ago, which collaborative and nursing actions will the nurse include in the plan of care (select all that apply)? a. Urinary catheter care b. Nasogastric (NG) tube feeding c. Continuous cardiac monitoring d. Maintain a warm room temperature e. Administration of H2 receptor blockers

a. Urinary catheter care c. Continuous cardiac monitoring d. Maintain a warm room temperature e. Administration of H2 receptor blockers The patient is at risk for bradycardia and poikilothermia caused by sympathetic nervous system dysfunction and should have continuous cardiac monitoring and maintenance of a relatively warm room temperature. Gastrointestinal (GI) motility is decreased initially and NG suctioning is indicated. To avoid bladder distention, a urinary retention catheter is used during this acute phase. Stress ulcers are a common complication, but can be avoided through the use of the H2 receptor blockers such as famotidine.

Which action will the nurse include in the plan of care for a 62-year-old patient who is experiencing pain from trigeminal neuralgia? a. Assess fluid and dietary intake. b. Apply ice packs for 20 minutes. c. Teach facial relaxation techniques. d. Spend time talking with the patient.

a. assess fluid and dietary intake The patient with an acute episode of trigeminal neuralgia may be unwilling to eat or drink, so assessment of nutritional and hydration status is important. Because stimulation by touch is the precipitating factor for pain, relaxation of the facial muscles will not improve symptoms. Application of ice is likely to precipitate pain. The patient will not want to engage in conversation, which may precipitate attacks.

Following a cauda equina spinal cord injury, which action will the nurse include in the plan of care? a. Catheterize patient every 3 to 4 hours. b. Assist patient to ambulate several times daily. c. Administer medications to reduce bladder spasm. d. Stabilize the neck when repositioning the patient.

a. catheterize patient every 3 to 4 hours Patients with cauda equina syndrome have areflexic bladder, and intermittent catheterization will be used for emptying the bladder. Because the bladder is flaccid, antispasmodic medications will not be used. The legs are flaccid with cauda equina syndrome and the patient will be unable to ambulate. The head and neck will not need to be stabilized following a cauda equina injury, which affects the lumbar and sacral nerve roots.

A nurse who works on the neurology unit just received change-of-shift report. Which patient will the nurse assess first? a. Patient with botulism who is experiencing difficulty swallowing b. Patient with Bell's palsy who has herpes vesicles in front of the ear c. Patient with neurosyphilis who has tabes dorsalis and decreased deep tendon reflexes d. Patient with an abscess caused by injectable drug use who needs tetanus immune globulin

a. patient with botulism who is experiencing difficulty swallowing The patient's diagnosis and difficulty swallowing indicate that the nurse should rapidly assess for respiratory distress. The information about the other patients is consistent with their diagnoses and does not indicate any immediate need for assessment or intervention.

A 32-year-old pregnant patient with Bell's palsy refuses to eat while others are present because of embarrassment about drooling. The best response by the nurse is to a. respect the patient's feelings and arrange for privacy at mealtimes. b. teach the patient to chew food on the unaffected side of the mouth. c. offer the patient liquid nutritional supplements at frequent intervals. d. discuss the patient's concerns with visitors who arrive at mealtimes.

a. respect the patient's feelings and arrange for privacy at mealtimes The patient's desire for privacy should be respected to encourage adequate nutrition and reduce patient embarrassment. Liquid supplements will reduce the patient's enjoyment of the taste of food. It would be inappropriate for the nurse to discuss the patient's embarrassment with visitors unless the patient wishes to share this information. Chewing on the unaffected side of the mouth will enhance nutrition and enjoyment of food but will not decrease the drooling.

A 39-year-old patient is being evaluated for a possible spinal cord tumor. Which finding by the nurse requires the most immediate action? a. The patient has new onset weakness of both legs. b. The patient complains of chronic severe back pain. c. The patient starts to cry and says, "I feel hopeless." d. The patient expresses anxiety about having surgery.

a. the patient has new onset weakness of both legs The new onset of symptoms indicates cord compression, which is an emergency that requires rapid treatment to avoid permanent loss of function. The other patient assessments also indicate a need for nursing action but do not require intervention as rapidly as the new onset weakness.

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

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

A 68-yr-old patient with a spinal cord injury has a neurogenic bowel. Beyond the use of bisacodyl suppositories and digital stimulation, which measures should the nurse teach the patient and caregiver to assist with bowel evacuation? Select all that apply. a. Drink more milk. b. Eat 20-30 g of fiber per day. c. Use oral laxatives every day. d. Limit caffeinated beverages. e. Drink 1800 to 2800 mL of water or juice. f. Establish bowel evacuation time at bedtime.

b. Eat 20-30 g of fiber per day. d. Limit caffeinated beverages. e. Drink 1800 to 2800 mL of water or juice. The patient with a spinal cord injury and neurogenic bowel should eat 20 to 30 g of fiber and drink 1800 to 2800 mL of water or juice each day. Caffeine stimulates fluid loss and can contribute to constipation, so caffeine intake should be limited. Milk also may cause constipation. Daily oral laxatives may cause diarrhea and are avoided unless needed. Bowel evacuation time usually is established 30 minutes after the first meal of the day to take advantage of the gastrocolic reflex induced by eating.

A nurse cares for a client with a lower motor neuron injury who is experiencing a flaccid bowel elimination pattern. Which actions should the nurse take to assist in relieving this client's constipation? (Select all that apply.) a. Pour warm water over the perineum. b. Provide a diet high in fluids and fiber. c. Administer daily tap water enemas. d. Implement a consistent daily time for elimination. e. Massage the abdomen from left to right. f. Perform manual disimpaction.

b. Provide a diet high in fluids and fiber. d. Implement a consistent daily time for elimination. f. Perform manual disimpaction. For the client with a lower motor neuron injury, the resulting flaccid bowel may require a bowel program for the client that includes stool softeners, increased fluid intake, a high-fiber diet, and a consistent elimination time. If the client becomes impacted, the nurse would need to perform manual disimpaction. Pouring warm water over the perineum, administering daily enemas, and massaging the abdomen would not assist this client.

The nurse is assessing a patient with a diagnosis of Guillain-Barre syndrome (GBS). Which signs and symptoms are consistent with GBS? (Select all that apply.) a. Bilateral sluggish pupil response b. Sudden onset of weakness in the legs c. Muscle atrophy of the legs d. Change in level of consciousness e. Decreased deep tendon reflexes f. Ataxia

b. Sudden onset of weakness in the legs e. Decreased deep tendon reflexes f. Ataxia

A patient reports "excruciating, sharp, shotting" unilateral facial pain which lasts from seconds to minutes and describes a reluctance to smile, eat, or talk because of fear of precipitating an attack. This patient's description of symptoms is consistent with the symptoms of which disorder? a. Peripheral nerve trauma b. Trigeminal neuralgia c. Bell's palsy d. Eaton-Lambert Syndrome

b. Trigeminal neuralgia

Which nursing action has the highest priority for a patient who was admitted 16 hours previously with a C5 spinal cord injury? a. Cardiac monitoring for bradycardia b. Assessment of respiratory rate and effort c. Application of pneumatic compression devices to legs d. Administration of methylprednisolone (Solu-Medrol) infusion

b. assessment of respiratory rate and effort Edema around the area of injury may lead to damage above the C4 level, so the highest priority is assessment of the patient's respiratory function. Methylprednisolone (Solu-Medrol) is no longer recommended for the treatment of spinal cord injuries. The other actions also are appropriate but are not as important as assessment of respiratory effort.

The nurse will explain to the patient who has a T2 spinal cord transection injury that a. use of the shoulders will be limited. b. function of both arms should be retained. c. total loss of respiratory function may occur. d. tachycardia is common with this type of injury.

b. function of both arms should be retained The patient with a T2 injury can expect to retain full motor and sensory function of the arms. Use of only the shoulders is associated with cervical spine injury. Loss of respiratory function occurs with cervical spine injuries. Bradycardia is associated with injuries above the T6 level.

Which action should the nurse take when assessing a patient with trigeminal neuralgia? a. Have the patient clench the jaws. b. Inspect the oral mucosa and teeth. c. Palpate the face to compare skin temperature bilaterally. d. Identify trigger zones by lightly touching the affected side.

b. inspect the oral mucosa and teeth Oral hygiene is frequently neglected because of fear of triggering facial pain. Having the patient clench the facial muscles will not be useful because the sensory branches of the nerve are affected by trigeminal neuralgia. Light touch and palpation may be triggers for pain and should be avoided.

A patient with paraplegia resulting from a T9 spinal cord injury has a neurogenic reflexic bladder. Which action will the nurse include in the plan of care? a. Teach the patient the Credé method. b. Instruct the patient how to self-catheterize. c. Catheterize for residual urine after voiding. d. Assist the patient to the toilet every 2 hours

b. instruct the patient how to self-catherize Because the patient's bladder is spastic and will empty in response to overstretching of the bladder wall, the most appropriate method is to avoid incontinence by emptying the bladder at regular intervals through intermittent catheterization. Assisting the patient to the toilet will not be helpful because the bladder will not empty. The Credé method is more appropriate for a bladder that is flaccid, such as occurs with areflexic neurogenic bladder. Catheterization after voiding will not resolve the patient's incontinence.

When the nurse is developing a rehabilitation plan for a 30-year-old patient with a C6 spinal cord injury, an appropriate goal is that the patient will be able to a. drive a car with powered hand controls. b. push a manual wheelchair on a flat surface. c. turn and reposition independently when in bed. d. transfer independently to and from a wheelchair.

b. push a manual wheelchair on a flat surface The patient with a C6 injury will be able to use the hands to push a wheelchair on flat, smooth surfaces. Because flexion of the thumb and fingers is minimal, the patient will not be able to grasp a wheelchair during transfer, drive a car with powered hand controls, or turn independently in bed.

A 20-year-old patient who sustained a T2 spinal cord injury 10 days ago angrily tells the nurse "I want to be transferred to a hospital where the nurses know what they are doing!" Which action by the nurse is best? a. Clarify that abusive language will not be tolerated. b. Request that the patient provide input for the plan of care. c. Perform care without responding to the patient's comments. d. Reassure the patient about the competence of the nursing staff.

b. request that the patient provide input for the plan of care The patient is demonstrating behaviors consistent with the anger phase of the grief process, and the nurse should allow expression of anger and seek the patient's input into care. Expression of anger is appropriate at this stage, and should be accepted by the nurse. Reassurance about the competency of the staff will not be helpful in responding to the patient's anger. Ignoring the patient's comments will increase the patient's anger and sense of helplessness.

Which assessment data for a patient who has Guillain-Barré syndrome will require the nurse's most immediate action? a. The patient's triceps reflexes are absent. b. The patient is continuously drooling saliva. c. The patient complains of severe pain in the feet. d. The patient's blood pressure (BP) is 150/82 mm Hg.

b. the patient is continuously drooling saliva Drooling indicates decreased ability to swallow, which places the patient at risk for aspiration and requires rapid nursing and collaborative actions such as suctioning and possible endotracheal intubation. The foot pain should be treated with appropriate analgesics, and the BP requires ongoing monitoring, but these actions are not as urgently needed as maintenance of respiratory function. Absence of the reflexes should be documented, but this is a common finding in Guillain-Barré syndrome.

The nurse assessing a 54-year-old female patient with newly diagnosed trigeminal neuralgia will ask the patient about a. visual problems caused by ptosis. b. triggers leading to facial discomfort. c. poor appetite caused by loss of taste. d. weakness on the affected side of the face.

b. triggers leading to facial discomfort The major clinical manifestation of trigeminal neuralgia is severe facial pain that is triggered by cutaneous stimulation of the nerve. Ptosis, loss of taste, and facial weakness are not characteristics of trigeminal neuralgia.

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

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

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

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

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

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

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

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

The nurse is caring for a client with Guillain-Barré syndrome (GBS) who is receiving intravenous immunoglobulin (IVIG). Which assessment finding warrants immediate evaluation? a. Chills b. Generalized malaise c. Headache with stiff neck d. Temperature of 99° F (37° C)

c. Headache with stiff neck A headache with a stiff neck may be a sign of aseptic meningitis, a possible serious complication of IVIG therapy. Chills, generalized malaise, and a low-grade fever are minor adverse effects of IVIG therapy and do not indicate that the therapy should be stopped.

A nurse assesses a client with a spinal cord injury at level T5. The client's blood pressure is 184/95 mm Hg, and the client presents with a flushed face and blurred vision. Which action should the nurse take first? a. Initiate oxygen via a nasal cannula. b. Place the client in a supine position. c. Palpate the bladder for distention. d. Administer a prescribed beta blocker

c. Palpate the bladder for distention. The client is manifesting symptoms of autonomic dysreflexia. Common causes include bladder distention, tight clothing, increased room temperature, and fecal impaction. If persistent, the client could experience neurologic injury. Precipitating conditions should be eliminated and the physician notified. The other actions would not be appropriate.

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

c. Raises the head of the bed to 45 degrees Raises the head of the bed to 45 degrees The head of the client's bed should be raised to 45 degrees because this allows for increased lung expansion, which improves the client's ability to breathe. Intubation is indicated only if dyspnea is severe or oxygen saturation does not respond to oxygen therapy. Close monitoring of respiratory status is indicated because of the acute stages of GBS. Instructing the client on how to cough effectively is not the priority in this case. The client should be suctioned only if needed to avoid vagal stimulation.

A nurse assesses a client with paraplegia from a spinal cord injury and notes reddened areas over the client's hips and sacrum. Which actions should the nurse take? (Select all that apply.) a. Apply a barrier cream to protect the skin from excoriation. b. Perform range-of-motion (ROM) exercises for the hip joint. c. Re-position the client off of the reddened areas. d. Get the client out of bed and into a chair once a day. e. Obtain a low-air-loss mattress to minimize pressure.

c. Re-position the client off of the reddened areas. e. Obtain a low-air-loss mattress to minimize pressure. Appropriate interventions to relieve pressure on these areas include frequent re-positioning and a low-air-loss mattress. Reddened areas should not be rubbed because this action could cause more extensive damage to the already fragile capillary system. Barrier cream will not protect the skin from pressure wounds. ROM exercises are used to prevent contractures. Sitting the client in a chair once a day will decrease the client's risk of respiratory complications but will not decrease pressure on the client's hips and sacrum.

A patient is diagnosed with Bell's palsy and the right side of the face is affected. Related to the patient's right eye, which nursing action is best to implement? a. Check the pupil size and reaction using a penlight. b. Check the patient's visual acuity in both eyes. c. Teach the patient to instill artificial tears four times a day. d. Teach the patient to prevent eye strain by resting eyes periodically.

c. Teach the patient to instill artificial tears four times a day.

When evaluating outcomes of a glycerol rhizotomy for a patient with trigeminal neuralgia, the nurse will a. assess whether the patient is doing daily facial exercises. b. question whether the patient is using an eye shield at night. c. ask the patient about social activities with family and friends. d. remind the patient to chew on the unaffected side of the mouth.

c. ask the patient about social activities with family and friends Because withdrawal from social activities is a common manifestation of trigeminal neuralgia, asking about social activities will help in evaluating whether the patient's symptoms have improved. Glycerol rhizotomy does not damage the corneal reflex or motor functions of the trigeminal nerve, so there is no need to use an eye shield, do facial exercises, or take precautions with chewing.

A patient admitted with dermal ulcers who has a history of a T3 spinal cord injury tells the nurse, "I have a pounding headache and I feel sick to my stomach." Which action should the nurse take first? a. Check for a fecal impaction. b. Give the prescribed analgesic. c. Assess the blood pressure (BP). d. Notify the health care provider.

c. assess the blood pressure The BP should be assessed immediately in a patient with an injury at the T6 level or higher who complains of a headache to determine whether autonomic dysreflexia is occurring. Notification of the patient's health care provider is appropriate after the BP is obtained. Administration of an antiemetic is indicated after autonomic dysreflexia is ruled out as the cause of the nausea. After checking the BP, the nurse may assess for a fecal impaction using lidocaine jelly to prevent further increased BP.

Which nursing action will the home health nurse include in the plan of care for a patient with paraplegia at the T4 level in order to prevent autonomic dysreflexia? a. Support selection of a high-protein diet. b. Discuss options for sexuality and fertility. c. Assist in planning a prescribed bowel program. d. Use quad coughing to strengthen cough efforts.

c. assist in planning a prescribed bowel program Fecal impaction is a common stimulus for autonomic dysreflexia. Dietary protein, coughing, and discussing sexuality/fertility should be included in the plan of care but will not reduce the risk for autonomic dysreflexia.

Which finding in a patient with a spinal cord tumor is most important for the nurse to report to the health care provider? a. Back pain that increases with coughing b. Depression about the diagnosis of a tumor c. Decreasing sensation and ability to move the legs d. Anxiety about scheduled surgery to remove the tumor

c. decreasing sensation and ability to move the legs Decreasing sensation and leg movement indicates spinal cord compression, an emergency that will require rapid action (such as surgery) to prevent paralysis. The other findings will also require nursing action but are not emergencies.

A 38-year-old patient has returned home following rehabilitation for a spinal cord injury. The home care nurse notes that the spouse is performing many of the activities that the patient had been managing unassisted during rehabilitation. The most appropriate action by the nurse at this time is to a. remind the patient about the importance of independence in daily activities. b. tell the spouse to stop because the patient is able to perform activities independently. c. develop a plan to increase the patient's independence in consultation with the patient and the spouse. d. recognize that it is important for the spouse to be involved in the patient's care and encourage that participation.

c. develop a plan to increase the patient's independence in consultation with the patient and the spouse The best action by the nurse will be to involve all the parties in developing an optimal plan of care. Because family members who will be assisting with the patient's ongoing care need to feel that their input is important, telling the spouse that the patient can perform activities independently is not the best choice. Reminding the patient about the importance of independence may not change the behaviors of the spouse. Supporting the activities of the spouse will lead to ongoing dependency by the patient.

The nurse is admitting a patient with a neck fracture at the C6 level to the intensive care unit. Which assessment finding(s) indicate(s) neurogenic shock? a. Hyperactive reflex activity below the level of injury b. Involuntary, spastic movements of the arms and legs c. Hypotension, bradycardia, and warm, pink extremities d. Lack of sensation or movement below the level of injury

c. hypotension bradycardia, and warm, pink extremities Neurogenic shock is characterized by hypotension, bradycardia, and vasodilation leading to warm skin temperature. Spasticity and hyperactive reflexes do not occur at this stage of spinal cord injury. Lack of movement and sensation indicate spinal cord injury, but not neurogenic shock.

A 33-year-old patient with a T4 spinal cord injury asks the nurse whether he will be able to be sexually active. Which initial response by the nurse is best? a. Reflex erections frequently occur, but orgasm may not be possible. b. Sildenafil (Viagra) is used by many patients with spinal cord injury. c. Multiple options are available to maintain sexuality after spinal cord injury. d. Penile injection, prostheses, or vacuum suction devices are possible options.

c. multiple options are available to maintain sexuality after spinal cord injury Although sexuality will be changed by the patient's spinal cord injury, there are options for expression of sexuality and for fertility. The other information also is correct, but the choices will depend on the degrees of injury and the patient's individual feelings about sexuality.

A 27-year-old patient is hospitalized with new onset of Guillain-Barré syndrome. The most essential assessment for the nurse to carry out is a. determining level of consciousness. b. checking strength of the extremities. c. observing respiratory rate and effort. d. monitoring the cardiac rate and rhythm

c. observing respiratory rate and effort The most serious complication of Guillain-Barré syndrome is respiratory failure, and the nurse should monitor respiratory function continuously. The other assessments will also be included in nursing care, but they are not as important as respiratory assessment.

A patient has an incomplete left spinal cord lesion at the level of T7, resulting in Brown-Séquard syndrome. Which nursing action should be included in the plan of care? a. Assessment of the patient for right arm weakness b. Assessment of the patient for increased right leg pain c. Positioning the patient's left leg when turning the patient d. Teaching the patient to look at the right leg to verify its position

c. positioning the patient's left leg when turning the patient The patient with Brown-Séquard syndrome has loss of motor function on the ipsilateral side and will require the nurse to move the left leg. Pain sensation will be lost on the patient's right leg. Arm weakness will not be a problem for a patient with a T7 injury. The patient will retain position sense for the right leg.

A patient who had a C7 spinal cord injury a week ago has a weak cough effort and audible rhonchi. The initial intervention by the nurse should be to a. administer humidified oxygen by mask. b. suction the patient's mouth and nasopharynx. c. push upward on the epigastric area as the patient coughs. d. encourage incentive spirometry every 2 hours during the day.

c. push upward on the epigastric area as the patient coughs Because the cough effort is poor, the initial action should be to use assisted coughing techniques to improve the ability to mobilize secretions. Administration of oxygen will improve oxygenation, but the data do not indicate hypoxemia. The use of the spirometer may improve respiratory status, but the patient's ability to take deep breaths is limited by the loss of intercostal muscle function. Suctioning may be needed if the patient is unable to expel secretions by coughing but should not be the nurse's first action.

A client with new-onset Bell's palsy is being discharged. Which statement made by the client demonstrates a need for further discharge teaching by the nurse? a. "I'll need artificial tears at least four times a day." b. "I will eat a soft diet." c. "My eye must be taped or patched at bedtime." d. "Narcotics will be needed for pain relief."

d. "Narcotics will be needed for pain relief." "Narcotics will be needed for pain relief." Mild analgesics, not narcotics, are used for pain associated with Bell's palsy. Artificial tears and taping the affected eye at night protect the cornea from drying out and potentially ulcerating because of the eye's inability to close. Mastication is often impaired with Bell's palsy, so soft foods are indicated.

The nurse is performing patient teaching about plasmapheresis. Which statement by the patient indicates understanding of the topic? a. "Plasmapheresis causes immunosuppression, so I am at risk for infection." b. "I will have to be admitted to the hospital for this procedure." c. "Two treatments are given over a 2-month period; then I must follow up on a monthly basis." d. "The goal of the treatment is to decrease symptoms, but it is not a cure."

d. "The goal of the treatment is to decrease symptoms, but it is not a cure."

A nurse teaches a client with a lower motor neuron lesion who wants to achieve bladder control. Which statement should the nurse include in this client's teaching? a. "Stroke the inner aspect of your thigh to initiate voiding." b. "Use a clean technique for intermittent catheterization." c. "Implement digital anal stimulation when your bladder is full." d. "Tighten your abdominal muscles to stimulate urine flow."

d. "Tighten your abdominal muscles to stimulate urine flow." In clients with lower motor neuron problems such as spinal cord injury, performing a Valsalva maneuver or tightening the abdominal muscles are interventions that can initiate voiding. Stroking the inner aspect of the thigh may initiate voiding in a client who has an upper motor neuron problem. Intermittent catheterization and digital anal stimulation do not initiate voiding or bladder control.

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

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

A patient with GBS has been intubated for respiratory failure. The nurse must suction the patient. In assessing the risk for vagal nerve stimulation, what does the nurse closely monitor the patient for? a. Thick secretions b. Atrial fibrillation c. Cyanosis d. Bradycardia

d. Bradycardia

An emergency room nurse initiates care for a client with a cervical spinal cord injury who arrives via emergency medical services. Which action should the nurse take first? a. Assess level of consciousness. b. Obtain vital signs. c. Administer oxygen therapy. d. Evaluate respiratory status.

d. Evaluate respiratory status. The first priority for a client with a spinal cord injury is assessment of respiratory status and airway patency. Clients with cervical spine injuries are particularly prone to respiratory compromise and may even require intubation. The other assessments should be performed after airway and breathing are assessed.

In which order will the nurse perform the following actions when caring for a patient with possible C5 spinal cord trauma who is admitted to the emergency department? (Put a comma and a space between each answer choice [A, B, C, D, E].) a. Infuse normal saline at 150 mL/hr. b. Monitor cardiac rhythm and blood pressure. c. Administer O2 using a non-rebreather mask. d. Immobilize the patient's head, neck, and spine. e. Transfer the patient to radiology for spinal computed tomography (CT).

d. Immobilize the patient's head, neck, and spine. c. Administer O2 using a non-rebreather mask. b. Monitor cardiac rhythm and blood pressure. a. Infuse normal saline at 150 mL/hr. e. Transfer the patient to radiology for spinal computed tomography (CT). The first action should be to prevent further injury by stabilizing the patient's spinal cord if the patient does not have penetrating trauma. Maintenance of oxygenation by administration of 100% O2 is the second priority. Because neurogenic shock is a possible complication, monitoring of heart rhythm and BP are indicated, followed by infusing normal saline for volume replacement. A CT scan to determine the extent and level of injury is needed once initial assessment and stabilization are accomplished.

A 68-year-old patient hospitalized with a new diagnosis of Guillain-Barré syndrome has numbness and weakness of both feet. The nurse will anticipate teaching the patient about a. intubation and mechanical ventilation. b. administration of corticosteroid drugs. c. insertion of a nasogastric (NG) feeding tube. d. infusion of immunoglobulin (Sandoglobulin).

d. infusion of immunoglobulin (Sandoglobulin) Because the Guillain-Barré syndrome is in the earliest stages (as evidenced by the symptoms), use of high-dose immunoglobulin is appropriate to reduce the extent and length of symptoms. Mechanical ventilation and tube feedings may be used later in the progression of the syndrome but are not needed now. Corticosteroid use is not helpful in reducing the duration or symptoms of the syndrome.

Which of these nursing actions for a 64-year-old patient with Guillain-Barré syndrome is most appropriate for the nurse to delegate to an experienced unlicensed assistive personnel (UAP)? a. Nasogastric tube feeding q4hr b. Artificial tear administration q2hr c. Assessment for bladder distention q2hr d. Passive range of motion to extremities q4hr

d. passive range of motion to extremities q4h Assisting a patient with movement is included in UAP education and scope of practice. Administration of tube feedings, administration of ordered medications, and assessment are skills requiring more education and scope of practice, and the RN should perform these skills.