Test 3. Level 4

The patient is diagnosed with chronic inflammatory demyelinating polyneuropathy (CIDP) after nerve conduction velocity test. How will this patient with CIDP be treated differently than a patient with Guillain-Barré syndrome? A. Rehabilitation B. Corticosteroids C. Plasmapheresis D. IV immunoglobulin

B. Corticosteroids

which condition is transmitted through wound contamination, causes painful tonic spasms or seizures, and can be prevented by immunization? A. Tetanus B. Botulism C. Neurosyphilis D. Systemic inflammatory response syndrome

A. Tetanus

How is urinary function best maintained during the acute phase of spinal cord injury? A. An indwelling catheter B. Intermittent catherization C. Insertion of a suprapuic catheter D. Use of incontinent pads to protect the skin

A. An indwelling catheter The bladder is atonic during the acute phase of spinal cord injury, causing urinary retention with the risk for reflux into the kidney or rupture of the bladder. An indwelling catheter is used to eep the bladder empty and monitor urinary output. Intermittent catheterization or other urinary drainage methods may be used in long term bladder management. Use of incontinent pads is inappropriate because they do not help the bladder empty

A patient is diagnosed with Bell's palsy. What information should the nurse teach about Bell's palsy? Select all that apply A. Bell's palsy affects the motor branches of the facial nerve B. Antiseizure drugs are the drugs of choice for treatment of bell's palsy C. Nutrition and avoiding hot foods or beverages are special needs of this patient D. Herpes simplex virus 1 is strongly associated with the development of Bell's palsy E. Moist heat, gentle massage, electrical nerve stimulation, and exercises are used to treat Bell's palsy F. An inability to close the eyelid, with an upward movement of the eyeball when closure is attempted, is evident

A. Bell's palsy affects the motor branches of the facial nerve D. Herpes simplex virus 1 is strongly associated with the development of Bell's palsy E. Moist heat, gentle massage, electrical nerve stimulation, and exercises are used to treat Bell's palsy F. An inability to close the eyelid, with an upward movement of the eyeball when closure is attempted, is evident Bell's palsy affects the motor branches of the facial nerve. Herpes simplex virus 1 or herpes zoster virus may be a precipitation factor. Moist heat, gentle massage, electrical nerve stimulation, and exercises are prescribed. Care must be taken to protect the eye with sunglasses and artificial tear or gel. Taping the eyelid closed at night may be helpful. Bell's palsy is treated with corticosteroids (usually prednisone), not anti seizure drugs. Oral hygiene is important. Avoiding hot foods is not needed.

Following a cauda equine spinal cord injury, which action will the nurse include in the plan of care? A. Catheterize patient every 3 - 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 - 4 hours Patients with caudal equine syndrome have a reflex 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 caudal equina syndrome and the patient will be unable to ambulate. The head and neck will not need to be stabilized following a caudal equine injury, which affects the lumbar and sacral nerve roots

Which syndrome of incomplete spinal cord injury is described as cord damage common in the cervical region that results in greater weakness in upper extremities than lower? A. Central cord syndrome B. Anterior cord syndrome C. Posterior cord syndrome D. Cauda equina and conus medullaris syndromes

A. Central cord syndrome In central cord syndrome, motor weakness and sensory loss are present in upper extremities; lower extremities are not usually affected.

Surgical intervention Is being considered for a patient with trigeminal neuralgia. The nurse recognizes that which procedure has the least residual effects with a positive outcome? A. Glycerol rhizotomy B. Gamma knife radiosurgery C. Microvascular decompression D Percutaneous radio frequency rhizotomy

A. Glycerol rhizotomy Glycerol rhizotomy causes less sensory loss ad fewer sensory aberrations with comparable pain relief and less danger than microvascular decompression and percutaneous radio frequency rhizotomy, although these provide greater pain relief. Gamma knife radio-surgery provides precise high doses of radiation useful for persistent pain after other surgery

During the patient's process of grieving for the losses resulting from spinal cord injury, what should the nurse do? A. Help the patient understand that woking through the grief will be a lifelong process B. Assist the patient to move through all stages of the mourning and grief process to acceptance C. Let the patient know that anger directed at the staff or the family is mot a positive coping mechanism D. Facilitate the grieving process so that it is completed by the time the patient is discharged from rehabilitation

A. Help the patient understand that woking through the grief will be a lifelong process Working through grief Is a lifelong process. It is triggered by new experiences, such as marriage, child rearing, employment, or illness, to which the patient must adjust throughout life within the context of their disability. The goal of recovery is related to adjustment rather than complete acceptance, and many patients do not experience all components of the tired process. During the anger phase, the patient should be allowed outburst. The nurse may use humor to displace some of the patient's anger.

A patient is admitted to the ED with a possible cervical spinal cord injury following an automobile crash. During admission of the patient, what is the highest priority for the nurse? A. Maintaining a patent airway B. Assessing the patient for head and other injuries C. Maintaining immobilization of the cervical spine D. Assessing the patient's motor and sensory function

A. Maintaining a patent airway The need ti a patent airway is the first priority for any injured patient. A high cervical injury may decrease the gag reflex and the ability to maintain an airway as well as the ability to breathe. Maintaining cervical stability is then a consideration, along with assessing neurologic status and for the presence of other injuries

when planning care for the patient with trigeminal neuralgia, which patient outcome should the nurse set as the highest priority? A. Relief of pain B. Protecting the cornea C. Maintaining optimal nutrition D. Maintaining a positive body image

A. Relief of pain The paint of trigeminal neuralgia is excruciating and may occur I clusters that continue for hours. The condition is considered benign with no major effects except the pain. Corneal exposure is a problem in Bell's palsy or it may occur after surgery for the treatment of trigeminal neuralgia. Maintaining optimal nutrition is important but not urgent. Chewing may trigger trigeminal neuralgia and the patient then avoids eating. Except during an attack, there is no change in facial appearance in a patient with trigeminal neuralgia. Body image is more disturbed in response to the paralysis typical of Bell's palsy.

The patient was in a traffic collision and has loss of function below C4. Which effect most influences how the nurse prioritizes care? A. Respiratory diaphragmatic breathing B. Loss of all respiratory muscle function C. Decreased response of the sympathetic nervous system

A. Respiratory diaphragmatic breathing A spinal cord injury below C4 will result in diaphragmatic breathing and usually hypoventilation from decreased vital capacity and tidal volume from intercostal muscle impairment. The nurse's priority actions will be to monitor rate, rhythm, depth, and effort of breathing to observe for changes from the baseline and identify the need for ventilation assistance. Loss of all respiratory muscle function occurs above C4, and the patient needs mechanical ventilation to survive. Although the decreased sympathetic nervous system response (from injuries above T6) and gastrointestinal (GI) hypomotility (paralytic ileum and gastric distention) will occur (with injuries above T5), they are not the patient's initial priority needs

A patient is admitted to the hospital with Guillain-Barré syndrome. She had weakness in her feet and ankles that has progressed to weakness with numbness and tingling in both legs. During the acute phase of the illness, what should the nurse know about Guillain-Barre syndrome? A. The most important aspect of care is to monitor the patient's respiratory rate and depth and vital capacity B. Early treatment with corticosteroids can suppress the immune response and prevent ascending nerve damage C. The most serious complication of this condition is ascending demyelination of the peripheral nerves and the cranial nerves D. Although voluntary motor neurons are damaged by the inflammatory response, the autonomic nervous system is unaffected by the disease

A. The most important aspect of care is to monitor the patient's respiratory rate and depth and vital capacity The most serious complication of Guillan-Barre syndrome is respiratory failure. It is essential that respiratory rate and depth, ABG's, and vital capacity are monitored to detect involvement of autonomic nerves that affect respiration. Corticosteroids do not appear to have an effect on the prognosis or duration of the disease. Rather plasmapheresis or high dose immunoglobulin result in shortening recovery time. The involvement of peripheral nerves of the sympathetic and parasympathetic nervous systems in the disease may cause orthostatic hypotension, hypertension, and abnormal vagal responses affecting the heart.

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 a 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 a 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 actions but do not require interventions as rapidly as the new onset weakness

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 poikilothermic caused by sympathetic nervous system dysfunction and should have continuous cardiac monitoring ad maintenance of a relatively warm room temperature. 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

In counseling patient with spinal cord injury about sexual functions, what should the nurse teach a male patient with a complete lower motor neuron lesion? A. He may have uncontrolled reflex erections, but orgasm and ejaculation are usually not possible B. He is most likely to have reflex erections and may have orgasm is S2-S4 nerve pathways are intact C. He has a lesion with the greatest possibility of successful psychogenic erection with ejaculation and orgasm D. He will probably be unable to have either psychogenic or reflex erections and no ejaculation or orgasm

B. He is most likely to have reflex erections and may have orgasm is S2-S4 nerve pathways are intact If S2-S4 nerve pathways are intact, the patient with a complete lower motor neuron lesion is able to have reflex erections and use drugs to maintain erection for sexual satisfaction. The patient with complete upper motor neuron lesions usually has only reflex sexual function with rare ejaculation. The patient with incomplete lower motor neuron lesions has the highest possibility of successful psychogenic erections with ejaculation. The patient with incomplete upper motor neuron lesions may have reflex erections with ejaculation.

A patient is admitted to the emergency department with spinal cord injury at the level of T2. Which assessment finding would most concern the nurse? A. Arterial oxygen saturation by pulse oximetry (SpO2) of 92% B. Heart rate of 42 bpm C. BP of 88/60 mmHg D. Loss of motor and sensory function in arms and legs

B. Heart rate of 42 bpm Neurogenic shock associated with spinal cord injury above the level of T6 greatly decreases the effect of the sympathetic nervous system, leading to bradycardia and hypotension. A heart rate of 42 bpm is not adequate to meet the oxygen needs of the body. While low, the BP is not at a critical point. The oxygen situation is satisfactory and the motor and sensory losses are expected.

A patient with paraplegia has developed an irritable bladder with reflex emptying. Along with possible use of medications, what will be most helpful for the nurse to teach the patient? A. Hygiene care for an indwelling urinary catheter B. How to perform intermittent self-catheterization C. To empty the bladder with manual pelvic pressure in coordination with reflex voiding patterns D. That a urinary diversion, such as an ileal conduit, is the easiest way to handle urinary elimination

B. How to perform intermittent self-catheterization Intermittent self-catheterization 4-6 times a day is the recommended method of bladder management for the patient with spinal cord injury and reflex neurogenic bladder because it more closely mimics normal emptying and has less potential for infection. The patient and family should be taught the procedure using clean technique at home. If the patient has use of the art, self catheterization should be performed. Indwelling catheterization is used during the acute phase to prevent over distention of the bladder. Surgical urinary diversions are used if urinary complications occur.

A patient with a metastatic tumor of the spinal cord is scheduled for removal of the tumor by a laminectomy. In planning postoperative care for the patient, what should the nurse recognize? A.Most cord tumors cause auto destruction of the cord as in traumatic injuries B. Metastatic tumors are commonly extradural lesions that are treated palliatively C. Radiation therapy Is routinely given after surgery for all malignant spinal cord tumors D. Because complete removal of intramedullary tumors are not possible, the surgery is considered palliative

B. Metastatic tumors are commonly extradural lesions that are treated palliatively Most metastatic or secondary tumors are extradural lesions in which treatment, including surgery, is palliative. Primary spinal tumors may be removed with the goal of cure. Most spinal cord tumor are slow growing and do not cause auto destruction. If removal is possible, complete function may be restored. Radiation is used to treat metastatic tumors that are sensitive to radiation and that have caused only minor neurologic deficits in the patient. Radiation is used as adjuvant therapy to surgery for intramedullary tumors.

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 patients 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 depression of anger and seek the patients input into care. Expression of anger is appropriate at this stage, and should e accepted by the nurse. Reassurance about the competency of the staff will not be helpful in responding to the patients anger. Ignoring the patients comments will increase the patients anger and sense of helplessness

The patient is diagnosed with brown-sequard syndrome after a knife wound to the spine. Which description accurately describes this syndrome? A. Damage to the most distal cord and nerve roots, resulting in flaccid paralysis of the lower limbs and areflexic bowel and bladder B. Spinal cord damage resulting in ipsilateral motor paralysis and contralateral loss of pain and sensation below the level of the injury C. Rare cord damage resulting in loss of proprioception below the lesion level with retention of motor control and temperature and pain sensation D. Often caused by flexion injury with acute compression of cord resulting in complete motor paralysis and loss of pain and temperature sensation below the level of injury

B. Spinal cord damage resulting in ipsilateral motor paralysis and contralateral loss of pain and sensation below the level of the injury Brown-sequard syndrome is characterized by ipsilateral loss of motor function and position and vibratory sense, and contralateral loss of pain and temperature sensation below the level of the injury. Damage to the most distal cord and verve roots with flaccid paralysis of the lower limbs and areflexic bowel and bladder is seen with cauda equine syndrome or cons medullaris syndrome. posterior cord syndrome is rare; cord damage results in loss of proprioception below the lesion level but retention of motor control and temperature and pain sensation. Anterior cord syndrome is often caused by flexion injury, with acute compression of the cord resulting in complete motor paralysis and loss of pain and temperature sensation below the level of injury; touch, position, vibration, and motion remain intact

A 70 year old patient is admitted after falling from his roof. He has a spinal cord injury at the C7 level. What assessment findings would indicate the presence of spinal shock? A. Paraplegia with a flaccid paralysis B. Tetraplegia with total sensory loss C. Total hemiplegia with sensory and motor loss D. Spastic tetraplegia with loss of pressure sensation

B. Tetraplegia with total sensory loss At the C7 level, spinal shock is manifested by tetraplegia and sensory loss. The neurologic loss may be temporary or permanent. Paraplegia with flaccid paralysis would occur at the level of T1 or below. Hemiplegia occurs with central (brain) lesions affecting motor neurons and spastic tetraplegia occurs when spinal shock resolves.

A week after spinal cord injury at T2, a patient has movement in his leg and tells the nurse that he is recovering some function. What is the nurse's best response to the patient? A. It is really still too soon to know if you will have a return of function B. That could be a really positive finding. Can you should me the movement? C. That's wonderful. We will start exercising your legs more frequently now. D. I'm sorry, but the movement is only a reflex and does not indicate normal function

B. That could be a really positive finding. Can you should me the movement? When spinal shock ends, reflex movement and spasms will occur that may be mistaken for return of function. However, with the resolution of edema, some normal function may also occur. When movement occurs, it is important to determine if the movement is voluntary and can be consciously controlled because this would indicate some return of function. If movement is not voluntary, reflex return will be explained.

Two days after spinal cord injury, a patient asks continually about the extent of impairment that will result from the injury. What is the best response by the nurse? A. You will have more normal function when spinal shock resolves and the reflex arc returns B. The extent of your injury cannot be determined until the secondary injury to the cord is resolved C. When your condition is more stable, MRI will be doe to reveal the extent of the cord damage D. Because rehabilitation can affect the return of function, it will be years before we can tell what the complete effect will be

B. The extent of your injury cannot be determined until the secondary injury to the cord is resolved Until edema and necrosis at th site of injury are resolved, it is not possible to determine how much cord damage is present from the initial injury, how much secondary injury occurred, ,or how much the cord as damaged by edema that extended above and below the level of the original injury. The return of reflexes signals the end of spinal shock. Reflexes may be inappropriate and excessive, causing spasms that complicate rehabilitation

Which nursing action has the highest priority for a patient who was admitted 16 hours previously with a C5 spinal 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 (sold-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 patients 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

A patient with paraplegia resulting from a T9 spinal cord injury has a neurogenic reflex bladder. Which action will the nurse include in the plan of care? A. teach the patient the cred 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 catheterize Because the patients bladder is spastic and will empty in response to overstretching of the bladder wall, the most appropriate method is to avoid incontinenve by emptying the bladder at regular intervals though intermittent catheterization. Assisting the patient to the toilet will not be helpful because the bladder will not empty. The cred method is more approriate for a bladder that is flaccid, such as occurs with areflexic neurogenic bladder. Catheterization after voiding will not resolve the patients 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 patient has an incomplete left spinal cord lesion at the level of T7, resulting in Brown-Squard 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 patients left leg when turning the patient D. Teaching the patient to look at the right leg to verify its position

C. Positioning the patients left leg when turning the patient The patient with brown square 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 patients 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

During assessment of a patient with spinal cord injury, the nurse determines that the patient has a poor cough with diaphragmatic breathing. Based on this finding, what should be the nurse's first action? A. Begin frequent turning and repositioning B. Use tracheal suctioning to remove secretions C. Assess lung sounds and respiratory rate and depth D. Prepare the patient for endotracheal intubation and mechanical ventilation

C. Assess lung sounds and respiratory rate and depth Because pneumonia and atelectasis are potential problems related to ineffective coughing and the loss of intercostal and abdominal muscle function, the nurse should assess the patients breath sounds and respiratory function to determine if secretions are being retained or respiratory impairment is progressing. If the patient cannot count to 10 aloud without taking a breath, immediate attention is needed. Suctioning is not indicated unless lung sounds indicate retained secretions. Position changes will help mobilize secretions. Intubation and mechanical ventilation are used if the patient becomes exhausted from labored breathing or if arterial blood gasses deteriorate

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.

The patient's spinal cord injury is at T4. What is the highest-level goal of rehabilitation that is realistic for this patient? A. Indoor mobility in manual wheelchair B. Ambulate with crutches and leg braces C. Be independent in self-care and wheelchair use D. Completely independent ambulation with short leg braces and canes

C. Be independent in self-care and wheelchair use With the injury at T4, the highest level realistic goal for this patient is to be independent in self-care and wheelchair use because arm function will not be affected. Indoor mobility in a manual wheelchair will be achievable, but it is not the highest level goal. Ambulating with crutches and leg braces can be achieved only by patients with injuries in T6-T12 area. Independent ambulation with short leg braces and canes could occur for a patient with an L3-4 injury

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

The nurse is admitting a patient with a neck fracture at the C6 level to the intensive care unit. Which assessment findings indicate 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 no neurogenic shock

What causes an initial incomplete spinal cord injury to result in complete cord damage? A. Edematous compression of the cord above the level of the injury B. Continued trauma to the cord resulting from damage to stabilizing ligaments C. Infarction and necrosis of the cord caused by edema, hemorrhage and metabolites D. Mechanical transection of the cord by sharp vertebral bone fragments after the initial injury

C. Infarction and necrosis of the cord caused by edema, hemorrhage and metabolites The primary spinal cord injury rarely affects the entire cord, but the pathophysiology of secondary injury may result in damage that is the same as mechanical severance of the cord. Complete cord dissolution occurs through auto destruction of the cord by hemorrhage, ischemia, edema, and the presence of metabolites, which can lead to cell death and permanent neurologic deficit

What should the nurse do when providing care for patient with an acute attack of trigeminal neuralgia? A. Carry out all hygiene and oral care for the patient B. Use conversation to distract the patient from pain C. Maintain a quiet, comfortable, draft-free environment D. Have the patient examine the mouth after each meal for residual food

C. Maintain a quiet, comfortable, draft-free environment Because attacks of trigeminal neuralgia may be precipitated by hot or cold air movement on the face, jarring movements, or talking, the environment should be of moderate temperature and free of drafts. The patient should not be expected to converse during the acute period. Patients often prefer to carry out their Own oral care because they are afraid someone else may inadvertently injure them or precipitate and attack. The nurse should stress that oral hygiene be done because patients often avoid it. Residual food in the mouth after eating occurs more often with Bell's palsy

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 patients spinal cord injury, there are options for expression of sexuality and for fertility. The other information also is correct, nut the choices will depend on the degrees of the injury and the patients individual feelings about sexuality

A patient with spinal cord injury has spinal shock. The nurse plans care for the patient based on what knowledge? A. Rehabilitation measure cannot be started until spinal shock has resolved. B. The patient needs continuous monitoring for hypotension, tachycardia, and hypoxemia C. Resolution of spinal shock is manifested by spasticity, reflex return, and neurogenic bladder D. Patient will have complete loss of motor and sensory functions below the level of the injury, but autonomic functions are not affected

C. Resolution of spinal shock is manifested by spasticity, reflex return, and neurogenic bladder Spinal shock occurs in many people with acute spinal cord injury. In spinal shock, the entire cord below the level of the lesion fails to functions, resulting in flaccid paralysis and hypo motility of most processes without any reflex activity. Return of reflex activity, although spastic, signals the end of spinal shock. Rehabilitation activities are not contraindicated during spinal shock and should be started if the patient's cardiopulmonary status is stable. Neurogenic shock results from loss of vascular tone from the injury. It is manifested by hypotension, peripheral vasodilation, and decreased cardiac output.

Before surgical stabilization of a cervical spinal cord injury, what method of patient immobilization should the nurse expect to be used? A. Kinetic beds B. Hard cervical collar C. Skeletal traction with skull tongs D. Sternal- occipital-mandibular immobilizer brace

C. Skeletal traction with skull tongs The development of better surgical stabilization has Mae surgery the more frequent treatment of cervical injuries. However, when surgery cannot be done, skeletal traction with the use of crutchfield, harder-wells, or other types of skull tongs is required to immobilize the cervical vertebrae, even if a fracture has not occurred. Special turning or kinetic beds may be used to turn and mobilize patients who are in cervical traction. Hard cervical collars or a sternal-occipital-mandibuar immobilizer brace may be used for stabilization during emergency transport of the patient, after cervical stabilization surgery, or for minor injuries

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 fecal impaction B. give the prescribed analgesic C. assess the blood pressure 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 patients 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

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 bee 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 Abe to perform activities independently C. develop a plan to increase the patients independence in consultation with the patient and the spouse D. recognize that is is important for the spouse to be involved in the patients care and encourage that participation

C. develop a plan to increase the patients 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 patients 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 dependence may not change the behaviors of the spouse. Supporting the activities of the spouse will lead to ongoing dependency by the patient

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 patients 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 e to use assisted coughing techniques to improve the ability to mobilize secretions. Administration of oxygen will impose oxygenation, but the data does not indicate hypoxemia. The use of the spirometer may improve respiratory status, but the patients 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 nurses first action

What is one indication for early surgical therapy of the patient with spinal cord injury? A. There is incomplete cord lesion involvement B. The ligaments that support the spine are torn C. A high cervical injury causes loss of respiratory function D. Evidence of continued compression of the cord is apparent

D. Evidence of continued compression of the cord is apparent Although surgical treatment of spinal cord injury often depends on the preference of the HCP, surgery is usually indicated when there is a continued compression of the cord by extrinsic forces or there is evidence of cord compression. Other indications may include progressive neurologic deficit, compound fracture of the vertebra, bony fragments, and penetrating wounds of the cord

what group should the nurse target when planning community education on preventing spinal cord injuries? A. Older men B. Teenage girls C. Elementary school-age children D. Adolescent and young adult men

D. Adolescent and young adult men Young adult men ages 16-30 years, who may be impulsive or risk takers in daily living, have the greatest risk for spinal cord injury. Other risk factors include alcohol and drug use, taking part in sports, and occupational exposure to trauma or violence.

The health care provider has prescribed IV norepinephrine (Levophed) for a patient in the ED with spinal cord injury. What observation indicates that the drug is having the desired effect? A. Heart rate of 69 bpm B. Respiratory rate of 24 breaths/min C. Temperature of 96.8 F D. BP of 206/82 mmHg

D. BP of 206/82 mmHg Norepinephrine is a vasopressor that is used to maintain BP during states of hypotension that occur during neurogenic shock associated with spinal cord injury. Atropine would be used to treat bradycardia. The temperature reflects some degree of poikilothermism, but this is not treated with medications

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? 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 patients head, heck, and spine E. Transfer the patient to radiology for spinal computed tomography (CT)

D. Immobilize the patients head, heck, 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 patients 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.

Following a T2 spinal cord injury, the patient develops paralytic ileum. While this condition is present, what should the nurse anticipate this patient will need? A. IV fluids B. Tube feedings C. Parenteral nutrition D. Nasogastric suctioning

D. Nasogastric suctioning During the first 2- 3 days after spinal cord injury, paralytic ileum may occur. Nasogastric suction must be used to remove secretions and gas from the GI tract until peristalsis resumes. IV fluids are used to maintain fluid balance but do not specifically relate to paralytic ileum. Tube feedings would be used only for patients who have difficulty swallowing, but to until peristalsis returns. Parenteral nutrition would be used only if the paralytic ileum was unusually prolonged.

A patient with spinal cord injury develops a throbbing headache, flushed skin, and diaphoresis above the level of injury. The nurse checks the patient''s vital signs and finds a systolic blood pressure of 210 mmHg and a heart rate of 40 bpm. Number the following nursing actions in order of priority from highest to lowest. A. Administer ordered as needed nitroglycerin B. Check for bladder distention C. Document the occurrence, treatment, and response D. Call the HCP E. Raise the head of bed to 45 degrees or above F. Loosen tight clothing on the patient

E. Raise the head of bed to 45 degrees or above B. Check for bladder distention D. Call the HCP F. Loosen tight clothing on the patient A. Administer ordered as needed nitroglycerin C. Document the occurrence, treatment, and response The patient has autonomic dysreflexia. The first response by the nurse should be to elevate the head of bed to decrease BP and then to remove noxious stimulation. Often the trigger is bladder distention, which can be addressed quickly by catheterization or ensuring drainage. The HCP must be notified as soon as possible. Meanwhile, the nurse should stay with the patient. If bladder distention was not the cause, a digital rectal examination with anesthetic ointment may be done. Loosen restrictive clothing. The HCP may order an antihypertensive. Documentation of the entire episode should be accurate and thorough.

A patient with Guillain-Barré syndrome asks whether he is going to die as the paralysis spreads toward his chest. In responding to the patient, what should the nurse know to be able to answer this question? a. Patients who require ventilatory support almost always die. b. Death occurs when nerve damage affects the brain and meninges. c. Most patients with Guillain-Barré syndrome make a complete recovery. d. If death can be prevented, residual paralysis and sensory impairment are usually permanent.

c. Most patients with Guillain-Barré syndrome make a complete recovery.