Test 6
The nurse should emphasize that the rehabilitation of the spinal cord-injured patient: 1.usually is achieved within a few months after stabilization 2.will return the spinal cord-injured patient to the pre-accident functional level. 3.focuses on adjustments necessary to reenter society and the workplace. 4.completely targets on self-care.
ANS:3 Modification of lifestyle and expectations and adjustments necessary to attain the highest level of independence possible are the goals of rehabilitation.
A patient with massive trauma and possible spinal cord injury is admitted to the emergency department (ED). Which finding by the nurse will help confirm a diagnosis of neurogenic shock?
Apical heart rate 48 beats/min
After falling from a 10 foot (3 meter) ladder, a patient is brought to the emergency department. The patient is alert, reports back pain, and difficulty moving the lower extremities. Which additional observation is an indication the patient may be experiencing neurogenic shock?
Bradycardia
Which of these nursing actions for a patient with Guillain-Barré syndrome is most appropriate for the nurse to delegate to an experienced nursing assistant? a. Nasogastric tube feeding q4hr b. Artificial tear administration q2hr c. Assessment for bladder distension q2hr d. Passive range of motion to extremities q8hr
Correct Answer: D Rationale: Assisting a patient with movement is included in nursing assistant 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. Cognitive Level: Application Text Reference: pp. 1586-1587 Nursing Process: Implementation NCLEX: Safe and Effective Care Environment
The home health registered nurse (RN) is planning care for a patient with a seizure disorder related to a recent head injury. Which nursing action can be delegated to a licensed practical/vocational nurse (LPN/LVN)? a. Make referrals to appropriate community agencies. b. Place medications in the home medication organizer. c. Teach the patient and family how to manage seizures. d. Assess for use of medications that may precipitate seizures.
ANS: B LPN/LVN education includes administration of medications. The other activities require RN education and scope of practice.
An elementary teacher who has just been diagnosed with epilepsy after having a generalized tonic-clonic seizure tells the nurse, "I cannot teach anymore, it will be too upsetting if I have a seizure at work." Which response by the nurse is best? a. "You might benefit from some psychologic counseling." b. "Epilepsy usually can be well controlled with medications." c. "You will want to contact the Epilepsy Foundation for assistance." d. "The Department of Vocational Rehabilitation can help with work retraining."
ANS: B The nurse should inform the patient that most patients with seizure disorders are controlled with medication. The other information may be necessary if the seizures persist after treatment with antiseizure medications is implemented.
While the nurse is transporting a patient on a stretcher to the radiology department, the patient begins having a tonic-clonic seizure. Which action should the nurse take? a. Insert an oral airway during the seizure to maintain a patent airway. b. Restrain the patient's arms and legs to prevent injury during the seizure. c. Time and observe and record the details of the seizure and postictal state. d. Avoid touching the patient to prevent further nervous system stimulation.
ANS: C Because the diagnosis and treatment of seizures frequently are based on the description of the seizure, recording the length and details of the seizure is important. Insertion of an oral airway and restraining the patient during the seizure are contraindicated. The nurse may need to move the patient to decrease the risk of injury during the seizure.
Which information about a 72-year-old patient who has a new prescription for phenytoin (Dilantin) indicates that the nurse should consult with the health care provider before administration of the medication? a. Patient has generalized tonic-clonic seizures. b. Patient experiences an aura before seizures. c. Patient's most recent blood pressure is 156/92 mm Hg. d. Patient has minor elevations in the liver function tests.
ANS: D Many older patients (especially with compromised liver function) may not be able to metabolize phenytoin. The health care provider may need to choose another antiseizure medication. Phenytoin is an appropriate medication for patients with tonic-clonic seizures, with or without an aura. Hypertension is not a contraindication for phenytoin therapy.
Which of these prescribed interventions will the nurse implement first for a hospitalized patient who is experiencing continuous tonic-clonic seizures? a. Give phenytoin (Dilantin) 100 mg IV. b. Monitor level of consciousness (LOC). c. Obtain computed tomography (CT) scan. d. Administer lorazepam (Ativan) 4 mg IV.
ANS: D To prevent ongoing seizures, the nurse should administer rapidly acting antiseizure medications such as the benzodiazepines. A CT scan is appropriate, but prevention of any seizure activity during the CT scan is necessary. Phenytoin will also be administered, but it is not rapidly acting. Patients who are experiencing tonic-clonic seizures are nonresponsive, although the nurse should assess LOC after the seizure.
The family of a spinal cord-injured patient is concerned with the lack of bowel function 2 days after injury. The nurse's best response would be: 1."Due to his injury, he will always need to have enemas for bowel evacuation." 2."Medical management is delaying bowel action, because it places pressure on the injury." 3."Bowel function should return about 3 days after the accident." 4."We'll just have to wait and see if bowel action returns this week."
ANS:1 Bowel action usually returns with peristalsis on the third postaccident day. The bowel responds to dilation from the content in the bowel and moves without voluntary action from the patient.
Which intervention by the nurse would be effective in the prevention of autonomic dysreflexia in the spinal cord-injured patient? 1.Ensure patency of the urinary catheter. 2.Give patient warm baths to stimulate vasodilation. 3.Keep lighting at a minimum to reduce stimulation. 4.Offer patient four or five small meals daily.
ANS:1 Distended bladder, constipation, and sudden jarring can all set off autonomic dysreflexia. Vagal stimulation retards vasodilation. The number and size of meals have no impact on prevention of this syndrome
When asked why the patient is receiving the drug methylprednisolone, the nurse explains that the drug is used in the spinal cord-injured patient to: 1.reduce spinal cord cellular damage. 2.counteract spinal shock. 3.increase blood supply to the injured cord. 4.enhance sexual function.
ANS:1 Methylprednisolone, if given within the first 8 hours of the injury, can markedly reduce cellular damage to the cord
A paraplegic patient excitedly reports seeing his foot move when he was being turned. This phenomenon is best explained as: 1.a reflexive movement. 2.a return of motor function. 3.an early symptom of autonomic dysreflexia. 4.a result of hypertonicity of the muscle.
ANS:1 Reflexive action is a movement that does not require communication to the brain via the spinal cord.
The nurse notes in a 2-hour postoperative laminectomy patient that there has been no urinary output. The nurse should: 1.continue to monitor. 2.inform the charge nurse. 3.perform intermittent catheterizations. 4.turn the patient to the right side.
ANS:1 The nurse should continue to monitor the patient for urine output. Two hours is too soon to expect a continent patient to void. There is no need to inform the charge nurse and no need for catheterization. Turning a laminectomy patient to the side is contraindicated.
After spinal shock has been resolved, the indwelling catheter is removed. The nurse tells the patient to expect the bladder to empty by: 1.manual expression (Credé method). 2.spontaneous reflexive action. 3.normal voluntary control. 4.self-catheterization.
ANS:2 After spinal shock resolves, spasticity of the bladder causes spontaneous emptying
Which assessment would indicate the resolution of spinal shock? 1.Extension and rigidity in affected limbs 2.Spastic involuntary movements in affected limbs 3.Tingling and burning in affected limbs 4.Voluntary purposeful movements of affected limbs
ANS:2 Spastic involuntary movements after a period of flaccid paralysis announce the end of spinal shock.
To test for hand grasp and strength, the nurse's arms are crossed and the patient is asked to squeeze the nurse's fingers. The purpose of crossed arms by the examiner is so that: 1.the nurse can get closer to the patient. 2.the patient's right-hand response is transmitted to the nurse's right hand and the left to the left. 3.the patient will be able to visualize the procedure better. 4.the muscle strength of the nurse's shoulders can be used if necessary.
ANS:2 The crossed arms ensure that the examiner will perceive the patient's response right to right and left to left
The family of a spinal cord-injured patient who is in the rehabilitation phase wants to take the patient outdoors for a visit. Because it is 90º outside and very humid, the nurse will suggest: 1.not going outside at all, but remaining in the hospital. 2.taking a spray bottle to spray water on the patient to cool by evaporation. 3.taking a light sweater for insulation of the patient. 4.that the patient drink at least 32 ounces of water during the outing.
ANS:2 Water will evaporate and cool the patient, just like perspiration
The nurse explains to the family of a quadriplegic that IV drugs are the most effective method of administration, because drugs injected by the IM method are: 1.too concentrated. 2.too irritating to poorly perfused tissue. 3.not absorbed well below the level of the injury. 4.too small a dose to be effective.
ANS:3 A quadriplegic has a high cervical lesion, which causes nearly the entire vascular tree to have poor perfusion. This would make absorption of medication from the tissues unpredictable
Following a CT scan, the nurse will encourage the spinal cord-injured patient to: 1.sit up at a 30-degree angle. 2.prevent chilling. 3.drink plenty of water. 4.avoid bearing down.
ANS:3 Fluids are pushed after a CT scan to flush the contrast media through the kidneys.
When the nurse recognizes autonomic dysreflexia in the spinal cord-injured patient, the immediate intervention should be to: 1.flex the patient's legs using the knee gatch of the bed 2.cool the patient with alcohol solution. 3.raise the head of the bed to at least 45 degrees. 4.administer oxygen per mask.
ANS:3 Raising the head of the bed reduces the BP. Flexed legs, cooling, and oxygen will not alleviate the syndrome.
Which statement made by a male spinal cord-injured patient could be assessed as a positive adaptation to the nursing diagnosis of "Sexual dysfunction related to altered body function"? 1."I know I will never have a sexual relationship again." 2."I need some suggestions as to how to direct my sexual energy into gardening or painting...or just anything." 3."Can you arrange an appointment with a sex counselor so I can begin to examine alternative methods of sexual activity?" 4."I think that after a while I will be able to have sexual relationships just like I had before my accident."
ANS:3 Seeking help from a counselor indicates acceptance of learning alternative techniques. Options 1 and 2 are defeatist remarks and are not positive. Option 4 reflects denial rather than acceptance
The family of a spinal cord-injured patient with an injury at C4 asks if the patient will ever be free of the ventilator. The nurse's best response is: 1."Yes. Rehabilitation is very difficult, but ventilator-free life can be accomplished." 2."No. A ventilator is essential to him." 3."Yes. There are special O2 masks that allow him time off the ventilator."
ANS:3 Small portable ventilators can be attached to wheelchairs for better patient mobility. Some patients can be trained to be off the ventilator for short periods of time.
On admission to the ER, the patient with a compression fracture at C5 can move only his head and has flaccid paralysis of all extremities. The distraught family asks if the paralysis is permanent. The nurse's best response would be: 1. "Yes. In all likelihood, the paralysis is probably permanent." 2."No. There should be marked recovery of function in a few days." 3."It is too early to tell. When spinal shock subsides, we will know more." 4."You should talk to your doctor about things of that nature."
ANS:3 Spinal shock due to swelling may last from a few days to months, clouding the issue of the true extent of the injury
Which technique of opening the airway in the newly admitted patient with spinal cord injury is the most appropriate? 1.Chin lift 2.Head tilt 3.Jaw thrust 4.Neck flexion
ANS:3 The jaw thrust does not require spinal movement.
During a neurologic check, the nurse asks the patient to dorsiflex the foot against the resistance of the nurse's hand. The inability to perform this action confirms that there is cord damage at: 1.C4-C5. 2.L2-L4. 3.L5. 4.S1.
ANS:3 The muscle group that controls the feet is at L5
The assessment that ensures the ER nurse that a patient's spinal cord injury is below C4 is: 1.voluntary eye movement. 2.ability to blink the eyelids. 3.unlabored respiration. 4.ability to make a facial grimace.
ANS:3 The phrenic nerve, which is at C1-C4, controls the diaphragm and intercostal function for ventilation
When the spinal cord-injured patient inquires what the doctor means by a "cone-down," the nurse explains that: 1.a cone is surgically placed over the spine to protect the cord. 2.marks will be placed on either side of the injury to mark the area. 3.a cone-shaped wedge of bone will be placed between the vertebra. 4.a very detailed x-ray will be taken of the spinal injury.
ANS:4 A cone-down x-ray results in a very detailed picture of the lesion
The nurse considering interventions for the outcome of prevention of contractures in a spinal cord-injured patient will include which of the following in the nursing care plan? 1.Apply cold wraps to the limbs twice a day. 2.Perform full range of motion every 2 hours. 3.Use significant tactile stimuli each shift. 4.Apply splints to the limbs.
ANS:4 Applying splints will reduce contractures. Cold application, agitation of the limb with ROM exercises too frequently, and tactile stimuli increase spasticity.
The spinal cord-injured patient begins to have seizures, and the blood pressure rises rapidly to 210/160. Which of the following is the third indicator of the dreaded syndrome of autonomic dysreflexia? 1.Profuse vomiting 2.Hives on face and neck 3.Excessive urine output 4.Bradycardia
ANS:4 Bradycardia, hypertension, and seizure are the three signs of autonomic dysreflexia
Which level of independence is an appropriate nursing care plan goal for a patient with a C8 transection? 1.Manage a mechanical wheelchair with a joystick 2.Manage a mechanical wheelchair with hand control 3.Manage a specially equipped wheelchair 4.Manage an ordinary wheelchair
ANS:4 Upper extremity mobility and enhanced hand grip allow the use of an ordinary wheelchair by someone with a C8 spinal cord injury
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.
Correct Answer: A. catheterize patient every 3 to 4 hours
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
Correct Answer: B. Assessment of respiratory rate and effort
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.
Correct Answer: B. push a manual wheelchair on a flat surface
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.
Correct Answer: B. request that the patient provide input for the plan of care
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
Correct Answer: C. decreasing sensation and ability to move the legs
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.
Correct Answer: C. develop a plan to increase the patient's independence in consultation with the patient and the spouse
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.
Correct Answer: C. multiple options are available to maintain sexuality after spinal cord injury
A patient has a tonic-clonic seizure while the nurse is in the patient's room. During the seizure, it is important for the nurse to a. insert an oral airway during the seizure to maintain a patent airway. b. restrain the patient's arms and legs to prevent injury during the seizure. c. avoid touching the patient to prevent further nervous system stimulation. d. time and observe and record the details of the seizure and postictal state.
Correct Answer: D Because diagnosis and treatment of seizures frequently are based on the description of the seizure, recording the length and details of the seizure is important. Insertion of an oral airway and restraining the patient during the seizure are contraindicated. The nurse may need to move the patient to decrease the risk of injury during the seizure.
Which information obtained about a 75-year-old patient with new-onset seizures will be of concern to the nurse when the patient is being started on therapy with phenytoin (Dilantin)? a. The patient has a history of chronic hepatitis C. b. The patient experienced menopause at age 52. c. The patient lives alone in an assisted living facility. d. The patient has had a recent right hemisphere stroke.
Correct Answer: A Phenytoin is metabolized by the liver, and the patient's age and history of hepatitis may increase the risk for toxic effects. The patient's age at menopause, living in an assisted living facility, and stroke history do not increase the risk for adverse effects of phenytoin.
A patient with a paraplegia resulting from a T10 spinal cord injury has a neurogenic reflex bladder. When the nurse develops a plan of care for this problem, which nursing action will be most appropriate? a. Teaching the patient how to self-catheterize b. Assisting the patient to the toilet q2-3hr c. Use of the Credé method to empty the bladder d. Catheterization for residual urine after voiding
Correct Answer: A Rationale: 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 a reflexic neurogenic bladder. Catheterization after voiding will not resolve the patient's incontinence. Cognitive Level: Application Text Reference: p. 1605 Nursing Process: Planning NCLEX: Physiological Integrity
During assessment of the patient with a recurrence of symptoms of trigeminal neuralgia, the nurse should a. examine the mouth and teeth thoroughly. b. have the patient clench and relax the jaw and eyes. c. identify trigger zones by lightly touching the affected side. d. gently palpate the face to compare skin temperature bilaterally.
Correct Answer: A Rationale: 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. Cognitive Level: Application Text Reference: p. 1583 Nursing Process: Assessment NCLEX: Physiological Integrity
When teaching patients who are at risk for Bell's palsy because of previous herpes simplex infection, which information should the nurse include? a. "You should call the doctor if pain or herpes lesions occur near the ear." b. "Treatment of herpes with antiviral agents will prevent development of Bell's palsy." c. "Medications to treat Bell's palsy work only if started before paralysis onset." d. "You may be able to prevent Bell's palsy by doing facial exercises regularly."
Correct Answer: A Rationale: Pain or herpes lesions near the ear may indicate the onset of Bell's palsy and rapid corticosteroid treatment may reduce the duration of Bell's palsy symptoms. Antiviral therapy for herpes simplex does not reduce the risk for Bell's palsy. Corticosteroid therapy will be most effective in reducing symptoms if started before paralysis is complete but will still be somewhat effective when started later. Facial exercises do not prevent Bell's palsy. Cognitive Level: Application Text Reference: p. 1585 Nursing Process: Implementation NCLEX: Physiological Integrity
A patient who sustained a T1 spinal cord injury a week ago refuses to discuss the injury and becomes verbally abusive to the nurses and other staff. The patient demands to be transferred to another hospital, where "they know what they are doing." The best response by the nurse to the patient's behavior is to a. ask for the patient's input into the plan for care. b. clarify that abusive behavior will not be tolerated. c. reassure the patient that the anger will pass and rehabilitation will then progress. d. ignore the patient's anger and continue to perform needed assessments and care.
Correct Answer: A Rationale: The patient is demonstrating behaviors consistent with the anger phase of the mourning 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 tolerated by the nurse. Refusal to acknowledge the patient's anger by telling the patient that the anger is just a phase is inappropriate. Continuing to perform needed assessments and care is appropriate, but the nurse should seek the patient's input into what care is needed. Cognitive Level: Application Text Reference: p. 1608 Nursing Process: Implementation NCLEX: Psychosocial Integrity
A patient with Bell's palsy refuses to eat while others are present because of embarrassment about drooling. The best response by the nurse to the patient's behavior is to a. respect the patient's desire and arrange for privacy at mealtimes. b. offer the patient liquid nutritional supplements at frequent intervals. c. discuss the patient's concerns with visitors who arrive at mealtimes. d. teach the patient to chew food on the unaffected side of the mouth.
Correct Answer: A Rationale: 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. Cognitive Level: Application Text Reference: p. 1585 Nursing Process: Implementation NCLEX: Psychosocial Integrity
For a 65 year old woman who has lived with a T1 spinal cord injury for 20 years, which of the following health teaching instructions should the nurse 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 injuries d. as a person ages, the need to change body position is less important
Correct Answer: A. a mammogram is needed every year
Urinary function during the acute phase of spinal cord injury is maintained with a. an indwelling catheter b. intermittent catheterization c. insertion of a suprapubic catheter d. use of incontinent pads to protect the skin
Correct Answer: A. an indwelling catheterization
A nurse is caring for a client who experienced a cervical spine injury 3 months ago. Which of the following types of bladder management methods should the nurse use for this client? a. condom catheter b. intermittent urinary catheterization c. crede's method d. indwelling urinary catheter
Correct Answer: A. condom catheter Rationale: a client who has a cervical spinal cord injury will also have a upper motor neuron injury, which is manifested by a spastic bladder. because the bladder will empty on its own, a condom catheter is an appropriate method and is noninvasive. B & C are for flaccid bladder.
During the patient's process of grieving for the losses resulting from spinal cord injury, the nurse a. helps the patient understand that working through the grief will be a lifelong process b. should assist the patient to move through all stages of the mourning process to acceptance c. lets the patient know that anger directed at the staff or the family is not a positive coping mechanism d. facilitates the grieving process so that it is completed by the time the patient is discharged from rehabilitation
Correct Answer: A. helps the patient understand that working through the grief will be a lifelong process
A patient is admitted to the emergency department with a possible cervical spinal cord injury following an automobile crash. During the admission of the patient, the nurse places the highest priority on 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
Correct Answer: A. maintaining a patent airway Rationale: The need for a patent airway is the first priority for any injured patient, and a high cervical injury may decrease the gag reflex and ability to maintain an airway, as well as the ability to breathe. Maintaining cervical stability is then a consideration, along with assessing for other injuries and the patients neuro status.
A nurse is planning care for a client who suffered a spinal cord injury (SCI) involving a T12 fracture 1 week ago. The client has no muscle control of the lower limbs, bowel, or bladder. which of the following should be the nurses' greatest priority? a. prevention of further damage to the spinal cord b. prevention of contractures of the lower extremities c. prevention of skin breakdown of areas that lack sensation d. prevention of postural hypotension when placing the client in a wheelchair
Correct Answer: A. prevention of further damage to the spinal cord Rationale: The greatest risk to the client during the acute phase of a SCI is further damage to the spinal cord. Therefore, when planning care, the priority should be the prevention of further damage to the spinal cord by administration of corticosteroids, minimizing movement of the client until spinal stabilization is accomplished through either traction or surgery, and adequate oxygenation of the client to decrease ischemia of the spinal cord.
When a patient experiences a generalized tonic-clonic seizure in the emergency department after a head injury, all of the following orders are received. Which one will the nurse implement first? a. Send to radiology for computed tomography (CT) scan. b. Administer midazolam (Versed). c. Check capillary blood glucose. d. Monitor level of consciousness (LOC).
Correct Answer: B To prevent ongoing seizures, the nurse should administer rapidly acting antiseizure medications such as the benzodiazepines. A CT scan is appropriate, but prevention of any seizure activity during the CT scan is necessary. Although the capillary blood glucose may offer information about the cause of the seizure, the initial nursing action is to decrease the risk for further seizures. Monitoring level of consciousness is important, but the highest priority is to decrease seizure risk.
When caring for a patient who has Guillain-Barré syndrome, which assessment data obtained by the nurse will require the most immediate action? a. The patient complains of severe tingling pain in the feet. b. The patient has continuous drooling of saliva. c. The patient's blood pressure (BP) is 106/50 mm Hg. d. The patient's quadriceps and triceps reflexes are absent.
Correct Answer: B Rationale: 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. Cognitive Level: Application Text Reference: pp. 1586-1587 Nursing Process: Assessment NCLEX: Physiological Integrity
A patient with Guillain-Barré syndrome asks the nurse what has caused the disease. In responding to the patient, the nurse explains that Guillain-Barré syndrome a. results from an acute infection and inflammation of the peripheral nerves. b. is due to an immune reaction that attacks the covering of the peripheral nerves. c. is caused by destruction of the peripheral nerves after exposure to a viral infection. d. results from degeneration of the peripheral nerve caused by viral attacks.
Correct Answer: B Rationale: Guillain-Barré syndrome is believed to result from an immunologic reaction that damages the myelin sheath of the peripheral nerves. Acute infection or inflammation of the nerves is not a cause. The peripheral nerves are not destroyed and do not degenerate. Cognitive Level: Comprehension Text Reference: pp. 1585-1586 Nursing Process: Implementation NCLEX: Physiological Integrity
A patient with a history of a T2 spinal cord tells the nurse, "I feel awful today. My head is throbbing, and I feel sick to my stomach." Which action should the nurse take first? a. Notify the patient's health care provider. b. Check the blood pressure (BP). c. Give the ordered antiemetic. d. Assess for a fecal impaction
Correct Answer: B Rationale: 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 causing the symptoms, including hypertension. 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. The nurse may assess for a fecal impaction, but this should be done after checking the BP and lidocaine jelly should be used to prevent further increases in the BP. Cognitive Level: Application Text Reference: p. 1603 Nursing Process: Assessment NCLEX: Physiological Integrity
When caring for a patient who had a C8 spinal cord injury 10 days ago and has a weak cough effort, bibasilar crackles, and decreased breath sounds, the initial intervention by the nurse should be to a. administer oxygen at 7 to 9 L/min with a face mask. b. place the hands on the epigastric area and push upward when the patient coughs. c. encourage the patient to use an incentive spirometer every 2 hours during the day. d. suction the patient's oral and pharyngeal airway.
Correct Answer: B Rationale: The nurse has identified that the cough effort is poor, so 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, and oxygen will not help expel respiratory secretions. 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. Cognitive Level: Application Text Reference: p. 1602 Nursing Process: Implementation NCLEX: Physiological Integrity
A patient with a T1 spinal cord injury is admitted to the intensive care unit (ICU). The nurse will teach the patient and family that a. use of the shoulders will be preserved. b. full function of the patient's arms will be retained. c. total loss of respiratory function may occur temporarily. d. elevations in heart rate are common with this type of injury.
Correct Answer: B Rationale: The patient with a T1 injury can expect to retain full motor and sensory function of the arms. Use of only the shoulders is associated with cervical spine injury. Total loss of respiratory function occurs with injuries above the C4 level and is permanent. Bradycardia is associated with injuries above the T6 level. Cognitive Level: Application Text Reference: p. 1594 Nursing Process: Implementation NCLEX: Physiological Integrity
When the nurse is planning care for a hospitalized patient who is experiencing an acute episode of trigeminal neuralgia, an appropriate action to include is a. teach facial and jaw relaxation techniques. b. assess intake and output and dietary intake. c. apply ice packs for no more than 20 minutes. d. spend time at the bedside talking with the patient.
Correct Answer: B Assess intake and output and dietary intake. Rationale: 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. Cognitive Level: Application Text Reference: p. 1583 Nursing Process: Planning NCLEX: Physiological Integrity
A patient is admitted to the emergency department with a spinal cord injury at the level of T2. Which of the following findings is of most concern to the nurse? a. SpO2 of 92% b. HR of 42 beats/min c. BP of 88/60 d. loss of motor and sensory function in arms and legs
Correct Answer: B. HR of 42 beats/min Rationale: Neurogenic shock associated with cord injuries above the level of T6 greatly decrease the effect of the sympathetic nervous system, and bradycardia and hypotension occur. A heart rate of 42 is not adequate to meet oxygen needs of the body, and while low, the BP is not at a critical point. The O2 sat is ok, and the motor and sensory loss are expected.
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.
Correct Answer: B. function of both arms should be retained
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.
Correct Answer: B. inspect the oral mucosa and teeth
A nurse is caring for a client with a spinal cord injury who reports a severe headache and is sweating profusely. vital signs include BP 220/110, apical heart rate of 54/min. Which of the following acctions should the nurse take first? a. notify the provider b. sit the client upright in bed c. check the client's urinary catheter for blockage d. administer antihypertensive medication
Correct Answer: B. sit the client upright in bed Rationale: The greatest risk to the client is experiencing a cerebrovascular accident (stroke) secondary to elevated BP. The first action by the nurse is elevate the head of the bed until the client is in an upright position. this will lower the BP secondary to postural hypotension.
A patient is admitted with a spinal cord injury at the C7 level. During assessment the nurse identifies the presence of spinal shock on finding a. paraplegia with flaccid paralysis b. tetraplegia with total sensory loss c. total hemiplegia with sensory and motor loss d. spastic tetraplegia with loss of pressure sensation
Correct Answer: B. tetraplegia with total sensory loss Rationale: At the C7 level, spinal shock is manifested by tetraplegia and sensory loss. The neurologic loss may be temporary or permanent. Paraplegia with sensory loss would occur at the level of T1. A hemiplegia occurs with central (brain) lesions affecting motor neurons and spastic tetraplegia occurs when spinal shock resolves.
A week following a spinal cord injury at T2, a patient experiences movement in his leg and tells the nurse he is recovering some function. The nurses' best response to the patient is: a. it is really still too soon to know if you will have a return of function b. the could be a really positive finding. can you show 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
Correct Answer: B. the could be a really positive finding. can you show me the movement Rationale: in 1 week following a spinal cord injury, there may be a resolution of the edema of the injury and an end to spinal shock. When spinal shock ends, reflex movement and spasms will occur, which may be mistaken for return of function, but with the resolution of edema, some normal function may also occur. it is important when movement occurs to determine whether the movement is voluntary and can be consciously controlled, which would indicate some return of function.
Two days following a spinal cord injury, a patient asks continually about the extent of impairment that will result from the injury. The best response by the nurse is, 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, an MRI will be done that can reveal the extent of the cord damage d. because long-term rehabilitation can affect the return of tunction, it will be years before we can tell when the complete effect will be
Correct Answer: B. the extent of your injury cannot be determined until the secondary injury to the cord is resolved Rationale: Until the edema and necrosis at the site of the injury are resolved in 72 hours to 1 week after the injury, 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 was damaged by edema that extended above the level of the original injury. The return of reflexes signals only the end of spinal shock, and the reflexes may be inappropriate and excessive, causing spasms that complicate rehab.
The health care provider prescribes phenytoin (Dilantin) for control of complex partial seizures. After the nurse has taught the patient about phenytoin, which patient statement indicates understanding of the medication? a. "I should use soft swabs rather than a toothbrush to clean my mouth." b."After I have a seizure, I should call an ambulance to take me to the hospital." c."I may need to have my blood taken frequently to check the level of the Dilantin." d. "I will take the medication at the beginning of the seizure when I experience an aura."
Correct Answer: C Serum levels of phenytoin may be checked to ascertain that a therapeutic level of the medication is achieved. Gingival hyperplasia associated with phenytoin use can be decreased by frequent brushing and flossing. Most seizures do not require hospitalization. The phenytoin is taken regularly to prevent seizures, not acutely when seizures occur.
When caring for a patient who was admitted 24 hours previously with a C5 spinal cord injury, which nursing action has the highest priority? a. Continuous cardiac monitoring for bradycardia b. Administration of methylprednisolone (Solu-Medrol) infusion c. Assessment of respiratory rate and depth d. Application of pneumatic compression devices to both legs
Correct Answer: C Rationale: 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. The other actions are also appropriate but are not as important as assessment of respiratory effort. Cognitive Level: Application Text Reference: p. 1602 Nursing Process: Assessment NCLEX: Physiological Integrity
The health care provider orders administration of IV methylprednisolone (Solu-Medrol) for the first 24 hours to a patient who experienced a spinal cord injury at the T10 level 3 hours ago. When evaluating the effectiveness of the medication the nurse will assess a. blood pressure and heart rate. b. respiratory effort and O2 saturation. c. motor and sensory function of the legs. d. bowel sounds and abdominal distension.
Correct Answer: C Rationale: The purpose of methylprednisolone administration is to help preserve neurologic function; therefore, the nurse will assess this patient for lower-extremity function. Sympathetic nervous system dysfunction occurs with injuries at or above T6, so monitoring of BP and heart rate will not be useful in determining the effectiveness of the medication. Respiratory and GI function will not be impaired by a T10 injury, so assessments of these systems will not provide information about whether the medication is effective. Cognitive Level: Application Text Reference: p. 1596 Nursing Process: Evaluation NCLEX: Physiological Integrity
A patient with Guillain-Barre syndrome asks whether he is going to die as the paralysis spreads toward his chest. In responding to the patient, the nurse knows that a. patient who require ventilatory support almost always die b. death occurs when nerve damage affects the brain and meninges c. most patient with Guillain-Barre syndrome make a complete recovery d. if death can be prevented, residual paralysis and sensory impairment are usually permanent
Correct Answer: C. most patient with Guillain-Barre syndrome make a complete recovery Rationale: As nerve involvement ascends, it is very frightening for the patient, but most patients with GBS recover completely with care. Patients also recover if ventilatory support is provided during respiratory failure. GBS affects only peripheral nerves and does not affect the brain.
The healthcare provider has ordered IV dopamine (Intropin) for a patient in the emergency deparement with a spinal cord injury. The nurse determines that the drug is having the desired effect when assessment findings include a. pulse rate of 68 b. respiratory rate of 24 c. BP of 106/82 d. temperature of 96.8
Correct Answer: C. BP of 106/82 Rationale: Dopamine 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 T reflects some degree of poikilothermism, but this is not treated with medications.
A patient with a C7 spinal cord injury undergoing rehabilitation tells the nurse he must have the flu because he has a bad headache and nausea. The initial action of the nurse is to a. call the physician b. check the patient's temperature c. take the patient's BP d. elevate the HOB to 90 degrees
Correct Answer: C. Take the patient's BP
During assessment of a patient with a spinal cord injury, the nurse determines that the patient has a poor cough with diaphragmatic breathing. Based on this finding, the nurses' first action should be to a. initiate 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
Correct Answer: C. assess lungs sounds and respiratory rate and depth Rationale: Because pneumonia and atelectasis are potential problems RT ineffective coughing function, the nurse should assess the patient's breath sound and respiratory function to determine whether secretions are being retained or whether there is progression of respiratory impairment. 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 ABGs 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.
Correct Answer: C. assist in planning a prescribed bowel program
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
Correct Answer: C. hypotension bradycardia, and warm, pink extremities
A patient with a spinal cord injury has spinal shock. The nurse plans care for the patient based on the knowledge that a. rehabilitation measures cannot be initiated until spinal shock has resolved b. the patient will need continuous monitoring for hypotension, tachycardia, and hypoxemia c. resolution of spinal shock is manifested by spasticity, hyperreflexia, and reflex emptying of the bladder d. the patient will have complete loss of motor and sensory functions below the level of the injury, but autonomic functions are not affected
Correct Answer: C. resolution of spinal shock is manifested by spasticity, hyperreflexia, and reflex emptying of the bladder Rationale: Spinal shock occurs in about half of all people with acute spinal cord injury. In spinal shock, the entire cord below the level of the lesion fails to function, resulting in a flaccid paralysis and hypomotility of most processes without any reflex activity. Return of reflex activity signals the end of spinal shock. Sympathetic function is impaired belwo the level of the injury because sympathetic nerves leave the spinal cord at the thoracic and lumbar areas, and cranial parasympathetic nerves predominate in control over respirations, heart, and all vessels and organ below the injury. Neurogenic shock results from loss of vascular tone caused by the injury and is manifested by hypotension, peripheral vasodilation, and decreased CO. Rehab activities are not contraindicated during spainl shock and should be instituted if the patient's cardiopulmonary status is stable.
After experiencing a generalized tonic-clonic seizure in the classroom, an elementary school teacher is evaluated and diagnosed with idiopathic epilepsy. The patient cries and tells the nurse, "I can not teach anymore. It will be too difficult for the students if this happens again at work." The most appropriate nursing diagnosis for the patient is a. anxiety related to loss of control during seizures. b. hopelessness related to diagnosis of chronic illness. c. disturbed body image related to new diagnosis of a seizure disorder. d. ineffective role performance related to misinformation about epilepsy.
Correct Answer: D The data indicate that the patient has ineffective role performance caused by inadequate information about the disease because most patients are able to control seizures with medication. Because the focus of the patient's statement is on career issues,
The nurse witnesses a patient with a seizure disorder as the patient suddenly jerks the arms and legs, falls to the floor, and regains consciousness immediately. It will be most important for the nurse to a. document the timing and description of the seizure. b. notify the patient's health care provider about the seizure. c. give the scheduled dose of divalproex (Depakote). d. assess the patient for a possible head injury.
Correct Answer: D The patient who has had a myoclonic seizure and fall is at risk for head injury and should be evaluated and treated for this possible complication first. Documentation of the seizure, notification of the seizure, and administration of antiseizure medications are also appropriate actions, but the initial action should be assessment for injury
A patient who has numbness and weakness of both feet is hospitalized with Guillain-Barré syndrome. The nurse will anticipate that collaborative interventions at this time will include a. intubation and mechanical ventilation. b. insertion of a nasogastric (NG) feeding tube. c. administration of methylprednisolone (Solu-Medrol). d. IV infusion of immunoglobulin (Sandoglobulin).
Correct Answer: D Rationale: 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. Cognitive Level: Application Text Reference: p. 1586 Nursing Process: Implementation NCLEX: Physiological Integrity
A patient with trigeminal neuralgia has a glycerol rhizotomy. During a follow-up visit after the rhizotomy, the nurse will evaluate that the patient has had a successful outcome for the surgery if the patient a. uses an eye shield at night to protect the cornea from injury. b. develops and implements a daily routine of facial exercises. c. is careful to chew foods on the unaffected side of the mouth. d. talks about enjoying social activities with family and friends.
Correct Answer: D Rationale: Because withdrawal from social activities is a common manifestation of trigeminal neuralgia, enjoyment of social activities indicates successful reduction of symptoms. 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. Cognitive Level: Application Text Reference: pp. 1583-1584 Nursing Process: Evaluation NCLEX: Physiological Integrity
A patient with a neck fracture at the C5 level is admitted to the intensive care unit (ICU) following initial treatment in the emergency room. During initial assessment of the patient, the nurse recognizes the presence of spinal shock on finding a. hypotension, bradycardia, and warm extremities. b. involuntary, spastic movements of the arms and legs. c. the presence of hyperactive reflex activity below the level of the injury. d. flaccid paralysis and lack of sensation below the level of the injury.
Correct Answer: D Rationale: Clinical manifestations of spinal shock include decreased reflexes, loss of sensation, and flaccid paralysis below the area of injury. Hypotension, bradycardia, and warm extremities are evidence of neurogenic shock. Involuntary spastic movements and hyperactive reflexes are not seen in the patient at this stage of spinal cord injury. Cognitive Level: Comprehension Text Reference: p. 1590 Nursing Process: Assessment NCLEX: Physiological Integrity
A 26-year-old patient with a C8 spinal cord injury tells the nurse, "My wife and I have always had a very active sex life, and I am worried that she may leave me if I cannot function sexually." The most appropriate response by the nurse to the patient's comment is to a. advise the patient to talk to his wife to determine how she feels about his sexual function. b. tell the patient that sildenafil (Viagra) helps to decrease erectile dysfunction in patients with spinal cord injury. c. inform the patient that most patients with upper motor neuron injuries have reflex erections. d. suggest that the patient and his wife work with a nurse specially trained in sexual counseling.
Correct Answer: D Rationale: Maintenance of sexuality is an important aspect of rehabilitation after spinal cord injury and should be handled by someone with expertise in sexual counseling. Although the patient should discuss these issues with his wife, open communication about this issue may be difficult without the assistance of a counselor. Sildenafil does assist with erectile dysfunction after spinal cord injury, but the patient's sexuality is not determined solely by the ability to have an erection. Reflex erections are common after upper motor neuron injury, but these erections are uncontrolled and cannot be maintained during coitus. Cognitive Level: Application Text Reference: p. 1608 Nursing Process: Implementation NCLEX: Psychosocial Integrity
A 25-year-old patient has returned home following extensive rehabilitation for a C8 spinal cord injury. The home care nurse visits and notices that the patient's spouse and parents are performing many of the activities of daily living (ADLs) that the patient had been managing during rehabilitation. The most appropriate action by the nurse at this time is to a. tell the family members that the patient can perform ADLs independently. b. remind the patient about the importance of independence in daily activities. c. recognize that it is important for the patient's family to be involved in the patient's care and support their activities. d. develop a plan to increase the patient's independence in consultation with the with the patient, spouse, and parents.
Correct Answer: D Rationale: 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 family that the patient can perform ADLs independently is not the best choice. Reminding the patient about the importance of independence may not change the behaviors of the family members. Supporting the activities of the spouse and parents will lead to ongoing dependency by the patient. Cognitive Level: Application Text Reference: p. 1609 Nursing Process: Implementation NCLEX: Psychosocial Integrity
When assessing a patient with newly diagnosed trigeminal neuralgia, the nurse will ask the patient about a. triggers that lead to facial pain. b. visual problems caused by ptosis. c. poor appetite caused by a loss of taste. d. decreased sensation on the affected side.
Correct Answer: D Rationale: 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 numbness are not characteristics of trigeminal neuralgia, although ptosis and numbness may occur after therapy, and poor appetite may be associated with pain stimulated by eating. Cognitive Level: Application Text Reference: p. 1581 Nursing Process: Assessment NCLEX: Physiological Integrity
A 24-year-old patient is hospitalized with the onset of Guillain-Barré syndrome. During this phase of the patient's illness, the most essential assessment for the nurse to carry out is a. monitoring the cardiac rhythm continuously. b. determining the level of consciousness q2hr. c. evaluating sensation and strength of the extremities. d. performing constant evaluation of respiratory function.
Correct Answer: D Rationale: 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. Cognitive Level: Comprehension Text Reference: p. 1586 Nursing Process: Assessment NCLEX: Physiological Integrity
The nurse discusses long-range goals with a patient with a C6 spinal cord injury. An appropriate patient outcome is a. transfers independently to a wheelchair. b. drives a car with powered hand controls. c. turns and repositions self independently when in bed. d. pushes a manual wheelchair on flat, smooth surfaces.
Correct Answer: D Rationale: 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. Cognitive Level: Application Text Reference: p. 1594 Nursing Process: Planning NCLEX: Physiological Integrity
In planning community education for prevention of spinal cord injuries, the nurse targets a. elderly men b. teenage girls c. elementary school-age children d. adolescent and young adult men
Correct Answer: D. adolescent and young adult men Rationale: Spinnal cord injuries are highest in young adult men between the ages of 15 and 30 and those who are impulsive or risk takers in daily living. Other risk factors include alcohol and drug abuse as well as participation in sports and occupational exposure to trauma or violence.
A patient is admitted to the hospital with a CD4 spinal cord injury after a motorcycle collision. The patient's BP is 83/49, and his pulse is 39 beats/min, and he remains orally intubated. The nurse identifies this pathophysiologic response as caused by a. increased vasomotor tone after 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
Correct Answer: D. loss of sympathetic nervous system innervation resulting in peripheral vasodilation
A nurse is caring for a client who experienced a cervical spine injury 24 hours ago. which of the following types of prescribed medications should the nurse clarify with the provider? a. glucocorticoids b. plasma expanders c. H2 antagonists d. muscle relaxants
Correct Answer: D. muscle relaxants Rationale: The client will still be in spinal shock 24 hours following the injury. the client will not experience muscle spasms until after the spinal shock has resolved, making muscle relaxants unnecessary at this time.
Following a T2 spinal cord injury, the patient develops paralytic ileus. While this condition is present, the nurse anticipates that the patient will need a. IV fluids b. tube feedings c. parenteral nutrition d. nasogastric suctioning
Correct Answer: D. nasogastric suctioning Rationale: During the first 2 to 3 days after a spinal cord injury, paralytic ileus may occur, and NG 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 ileus. Tube feedings would be used only for patients who had difficulty swallowing and not until peristalsis is returned; PN would be used only if the paralytic ileus was unusually prolonged.
A nurse is caring for a client who has a C4 spinal cord injury. which of the following should the nurse recognize the client as being at the greatest risk for? a. neurogenic shock b. paralytic ileus c. stress ulcer d. respiratory compromise
Correct Answer: D. respiratory compromise Rationale: Using the airway, breathing and circulation priority framework, the greatest risk to the client with a SCI at the level of C4 is respiratory compromise secondary to involvement of the phrenic nerve. Maintainance of an airway and provision of ventilator support as needed is the priority intervention.
In counseling patient with spinal cord lesions regarding sexual function, the nurse advises a male patient with a complete lower motor neuron lesion that he a. is most likely to have reflexogenic erections and may experience orgasm if ejaculation occurs b. may have uncontrolled reflex erections, but that orgasm and ejaculation are usually not possible c. has a lesion with the greatest possibility of successful psychogenic erection with ejaculation and orgasm d. will probably be unable to have either psychogenic or reflexogenic erections with no ejaculation or orgasm
Correct Answer: D. will probably be unable to have either psychogenic or reflexogenic erections with no ejaculation or orgasm Rationale: Most patients with a complete lower motor neuron lesion are unable to have either psychogenic or reflexogenic erections, and alterative methods of obtaining sexual satisfaction may be suggested. Patients with incomplete lower motor neuron lesions have the highest possibility of successful psychogenic erections with ejaculation, whereas patients with incomplete upper motor neuron lesions are more likey to experience reflexogeic erections with ejaculation. Patients with complete upper motor neuron lesions usually only have reflex sexual function with rare ejaculation.
When planning care for the patient with trigeminal neuralgia, the nurse sets the highest priority on the patient outcome of a. relief of pain b. protection of the cornea c. maintenance of nutrition d. maintenance of positive body image
Correct Answer: a. relief of pain rationale: The pain of trigeminal neuralgia is excrutiating, and it may occur in clusters that continue for hours. The condition is considered benign with no major effects except the pain.
When preparing to admit a patient who has been treated for status epilepticus in the emergency department, which equipment should the nurse have available in the room? (Select all that apply.) a. Suction tubing b. Oxygen mask c. Nasogastric tube d. Siderail pads e. Tongue blade f. Oral airway
Correct Answers: A, B, D The patient is at risk for further seizures, and oxygen and suctioning may be needed after any seizures to clear the airway and maximize oxygenation. The bed's side rails should be padded to minimize the risk for patient injury during a seizure. Insertion of a nasogastric (NG) tube is not indicated because the airway problem is not caused by vomiting or abdominal distention. Use of tongue blades or oral airways during a seizure is contraindicated.
A patient is admitted to the hospital with Guillain-Barre syndrome. She had a weakness in her feet and ankles that has progressed to weakness with numbness and tingling in both legs. During the acute phase of her illness, the nurse recognizes that 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 damages c. although voluntary motor neurons are damaged by the inflammatory response, the autonomic nervous system is unaffected by the disease d. the most serious complication of this condition is ascending demyelination of the peripheral nerves of the lower brainstem and cranial nerves
Correct answer: A. the most important aspect of care is to monitor the patient's respiratory rate and depth and vital capacity Rationale: The most serious complication of GBS is respiratory failure, and it is essential that respiratory rate, depth, and vital capacity are monitored to detect involvement of the nerves that affect respiration. Corticosteroids may be used in treatment but do not appear to have an effect on the prognosis or duration of the disease. Rather, plasmapheresis or administration of high dose immunoglobulin does result in shortening recovery time. The peripheral nerves of both the sympathetic and parasympathetic NS are involved in the disease and may lead to orthostatic hypotension, hypertension, and may abnormal vagal responses affecting the heart.
When the charge nurse is evaluating the skills of a new RN, which action by the new RN indicates a need for more education in the care of patients with shock?
Decreasing the room temperature to 68° F for a patient with neurogenic shock