Unit 4 Mobility - Spinal Cord Injury

Which nursing activity could be appropriately delegated to unlicensed assistive personnel (UAP) (Select all that apply.)? Test C.R.'s stool specimen for hemoccult blood. Remove and reapply compression stockings q4hr. Turn C.R. side to side q2hr to prevent skin breakdown. Monitor patient's intake and output to evaluate the patient's fluid balance. Assess lung sounds bilaterally.

Test C.R.'s stool specimen for hemoccult blood. Remove and reapply compression stockings q4hr. Turn C.R. side to side q2hr to prevent skin breakdown.

26. Which action should the nurse take when caring for a patient who develops tetanus from injectable substance use? a. Avoid use of sedatives. b. Provide a quiet environment. c. Provide range-of-motion exercises daily. d. Check pupil reaction to light every 4 hours.

ANS: B In patients with tetanus, jarring, loud noises or bright lights can precipitate painful seizures. The nurse will minimize noise and avoid shining light into the patient's eyes. Range-of-motion exercises may also stimulate the patient and cause seizures. Although the patient has a history of injectable drug use, sedative medications will be needed to decrease spasms.

A patient with massive trauma and possible spinal cord injury is admitted to the emergency department (ED). Which assessment finding by the nurse will help confirm a diagnosis of neurogenic shock? a. Inspiratory crackles b. Heart rate 45 beats/min c. Cool, clammy extremities d. Temperature 101.2° F (38.4° C)

ANS: B Neurogenic shock is characterized by hypotension and bradycardia. The other findings would be more consistent with other types of shock.

11. The nurse is admitting a patient who has a neck fracture at the C6 level to the intensive care unit. Which finding on the nursing assessment is congruent with neurogenic shock? a. Involuntary and spastic movement b. Hypotension and warm extremities c. Hyperactive reflexes below the injury d. Lack of sensation or movement below the injury

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

16. A 20-yr-old patient who sustained a T2 spinal cord injury 10 days ago tells the nurse, "I want to be transferred to a hospital where the nurses know what they are doing." Which action should the nurse appropriately take? a. Perform care without responding to the comments. b. Ask the patient to provide input for the plan of care. c. Tell the patient abusive language will not be tolerated. d. Reassure the patient about the competence of the nursing staff.

ANS: B The patient is demonstrating behaviors consistent with the anger phase of the grief process. The nurse should allow expression of anger and seek the patient's input into care. Expression of anger is appropriate at this stage and should be accepted by the nurse. Reassurance about the competency of the staff will not be helpful in addressing the patient's concerns. Ignoring the patient's comments will increase the patient's anger and sense of helplessness.

13. What should the nurse explain to the patient who has a T2 spinal cord transection injury? a. Total loss of respiratory function may occur. b. Function of both arms should be maintained. c. Use of the patient's shoulders will be limited. d. Tachycardia is common with this type of injury.

ANS: B 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.

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

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

21. What action should the nurse identify as most important before administering botulinum antitoxin to a patient in the emergency department? a. Obtain the patient's temperature. b. Administer an intradermal test dose. c. Document the neurologic symptoms. d. Ask the patient about an allergy to eggs.

ANS: B To assess for possible allergic reactions, the nurse should administer an intradermal test dose of the antitoxin. Although temperature, allergy history, and symptom assessment and documentation are appropriate, these assessments will not affect the decision to administer the antitoxin.

3. What action would help the nurse evaluate outcomes of a glycerol rhizotomy for a patient with trigeminal neuralgia? a. Inquire if the patient is doing daily facial exercises. b. Question if the patient is using an eye shield at night. c. Ask the patient about social activities with family and friends. d. Observe the patient chewing with the unaffected side of the mouth.

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

29. Which assessment finding in a patient with a spinal cord tumor requires immediate action by the nurse? a. Depression about the diagnosis b. Anxiety about scheduled surgery c. Decreased ability to move the legs d. Back pain that worsens with coughing

ANS: C 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 require nursing action but are not emergencies.

8. Which assessment data for a patient who has Guillain-Barré syndrome will require the nurse's most immediate action? a. The patient's sacral area skin is reddened. b. The patient reports severe pain in the feet. c. The patient is continuously drooling saliva. d. The patient's blood pressure (BP) is 150/82 mm Hg.

ANS: C 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, the BP requires ongoing monitoring, and the skin integrity requires intervention, but these actions are not as urgently needed as maintenance of respiratory function.

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

ANS: C Fecal impaction is a common stimulus for autonomic hyperreflexia. Dietary protein, coughing, and discussing sexuality and fertility should be included in the plan of care but will not reduce the risk for autonomic hyperreflexia.

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

ANS: C The BP should be assessed immediately when a patient with an injury at the T6 level or higher reports a headache. This will help determine if autonomic hyperreflexia is occurring. Notification of the patient's health care provider is appropriate after the BP is obtained. Administration of an antiemetic is indicated if 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.

17. A 38-yr-old patient who has had a spinal cord injury returned home following a stay in a rehabilitation facility. The home care nurse notes the spouse is performing many of the activities that the patient had been managing unassisted during rehabilitation. What should the nurse identify as the most appropriate action at this phase of rehabilitation? a. Remind the patient about the importance of independence in daily activities. b. Tell the spouse to stop helping because the patient can 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 participation.

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

A patient who has neurogenic shock is receiving a phenylephrine infusion through a right forearm IV. Which assessment finding obtained by the nurse indicates a need for immediate action? a. The patient's heart rate is 58 beats/min. b. The patient's extremities are warm and dry. c. The patient's IV infusion site is cool and pale. d. The patient's urine output is 28 mL over the past hour.

ANS: C The coldness and pallor at the infusion site suggest extravasation of the phenylephrine. The nurse should discontinue the IV and, if possible, infuse the drug into a central line. An apical pulse of 58 beats/min is typical for neurogenic shock but does not indicate an immediate need for nursing intervention. A 28-mL urinary output over 1 hour would require the nurse to monitor the output over the next hour, but an immediate change in therapy is not indicated. Warm, dry skin is consistent with early neurogenic shock, but it does not indicate a need for a change in therapy or immediate action.

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

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

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

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

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

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

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

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

A 22-yr-old woman with paraplegia after a spinal cord injury tells the home care nurse she has bowel incontinence 2 or 3 times each day. Which action should the nurse perform first? Insert a rectal stimulant suppository. Have the patient to gradually increase intake of high-fiber foods. Assess bowel movements for frequency, consistency, and volume. Teach the patient to avoid all caffeinated and carbonated beverages.

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

A patient with a spinal cord injury has a neurogenic bowel. Beyond the use of bisacodyl suppositories and digital stimulation, which measures should the nurse teach the patient and caregiver to assist with bowel evacuation? (Select all that apply.) Drink milk with each meal. Eat 20 to 30 g of fiber per day Use an oral laxative every day. Limit intake of caffeinated beverages Drink 1800 to 2800 mL of water or juice. Establish bowel evacuation time at bedtime

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

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

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

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

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

Which assessment findings in a patient with a thoracic spinal cord injury (T4) would alert the nurse to possible autonomic dysreflexia? Headache and rising blood pressure Irregular respirations and shortness of breath Abdominal distention and absence of bowel sounds Decreased level of consciousness and hallucinations

Correct Answer: Headache and rising blood pressure Rationale: Manifestations of autonomic dysreflexia are hypertension (up to 300 mm Hg systolic), a throbbing headache, bradycardia, and diaphoresis. Respiratory changes, decreased level of consciousness, and gastrointestinal problems are not characteristic manifestations.

The nurse is caring for a patient with a halo vest after cervical spine injury. Which care instructions should the nurse include in the patient's discharge plan? Keep a wrench close or attached to the vest. Use the frame and vest to assist in positioning. Clean around the pins using betadine swab sticks. Loosen both sides of the vest to provide skin care.

Correct Answer: Keep a wrench close or attached to the vest. Rationale: A halo vest is used to provide cervical spine immobilization while vertebrae heal. There should always be a wrench with the halo vest in case emergency removal of the vest is needed (e.g., performance of CPR). Cleaning around the pins is typically performed with normal saline or chlorhexidine, based on provider instructions. Only one side of the vest can be loosened for skin care and changing clothes. After that side has been reattached, the other side of the vest can be loosened.

The nurse is providing care for a patient diagnosed with Guillain-Barré syndrome. Which assessment should be the nurse's priority? Pain assessment Glasgow Coma Scale Respiratory assessment Musculoskeletal assessment

Correct Answer: Respiratory assessment Rationale: Although all the assessments are necessary in the care of patients with Guillain-Barré syndrome, the acute risk of respiratory failure requires vigilant monitoring of the patient's respiratory function.

The nurse is caring for a patient admitted with a spinal cord injury after a motor vehicle accident. The patient has a complete loss of motor, sensory, and reflex activity below the injury level. The nurse recognizes this condition as: central cord syndrome. spinal shock syndrome. anterior cord syndrome. Brown-Séquard syndrome.

Correct Answer: spinal shock syndrome. Rationale: About 50% of people with acute spinal cord injury develop spinal shock, a temporary loss of reflexes, sensation, and motor activity. Central cord syndrome is manifested by motor and sensory loss greater in the upper extremities than the lower extremities. Anterior cord syndrome results in motor and sensory loss but not loss of reflexes. Brown-Séquard syndrome is characterized by ipsilateral loss of motor function and contralateral loss of sensory function.

Case Study C.R. is a 42-year-old white male who fell from a 60-foot scaffold while working on the construction of a new building. He is admitted to the emergency department (ED) by ambulance and is strapped to a rigid backboard with cervical immobilization. At the site of the accident, C.R.'s co-workers immobilized his body until the ambulance arrived. His supervisor called his wife.C.R.'s wife arrives at the emergency department (ED) at the same time the ambulance arrives. She is very agitated and crying. He sees her as he is wheeled into the ED, reassures her that he is okay, and tells her he fell at work. You take her to a waiting room, explaining that she can see her husband as soon as he is stabilized.Initial physical findings include a flaccid paralysis and loss of sensation of the lower extremities and trunk. He has sensation and movement of the arms and hands with decreased grasp strength. His extremities are warm and dry. Vital signs are BP 88/50, hear rate (HR) 40 beats/minute, respiratory rate (RR) 26 breaths/minute and shallow, and temperature 97°F (36.1°C). His clothing is torn in several places, revealing a large abrasion on his right shoulder, a bruised right upper arm, and a deeply abraded right upper leg. He complains of burning pain in his right upper arm and shoulder. He had bowel and bladder incontinence at the site of the accident but does not seem aware of it. He has a peripheral IV of normal saline running at 75 mL/hr started by the paramedics. C.R.'s airway is not compromised, and he remains immobilized on the backboard. To plan care for C.R., you anticipate the emergency management that may be indicated. Select the interventions that might be indicated in the emergency management of C.R. There are 9 correct answers. Administration of high-dose methylprednisolone Administration of prophylactic antibiotics X-rays of the spine Spinal CT scan and/or MRI Administration of atropine Administration of morphine Endotracheal intubation Administration of vasopressors such as dopamine Insertion of a nasogastric tube to suction Insertion of an indwelling catheter Application of a cooling blanket Initiation of a second lrage-bore IV site Administration of oxygen Cardiac monitoring

X-rays of the spine Spinal CT scan and/or MRI Administration of atropine Administration of vasopressors such as dopamine Insertion of a nasogastric tube to suction Insertion of an indwelling catheter Initiation of a second lrage-bore IV site Administration of oxygen Cardiac monitoring

After 9 days, C.R.'s spinal shock resolves and his reflexes return. His indwelling urinary catheter has been removed, and an intermittent catheterization program has been started. A bowel program with the use of suppositories and stool softeners has also been instituted. He is eating solid food and drinking fluids without difficulty. When you enter his room in the morning to transport him to physical therapy, he states that he doesn't want to go this morning because he has a headache that is causing blurred vision. You recognize the fact that he may be experiencing autonomic dysreflexia. This process is characterized by severe hypotension caused by vasodilation of vessels below the level of the injury. a sympathetic nervous system response to sensory stimulation resulting in marked hypertension. tachycardia and diaphoresis resulting from parasympathetic stimulation of the cardiovascular system. blockade of the autonomic ganglia throughout the spinal cord resulting in cardiovascular collapse.

a sympathetic nervous system response to sensory stimulation resulting in marked hypertension. The pathology of autonomic dysreflexia involves the stimulation of sensory receptors below the level of the SCI. The intact sympathetic nervous system below the level of the injury responds to the stimulation with a reflex arteriolar vasoconstriction that increases blood pressure, but the parasympathetic nervous system is unable to directly counteract these responses via the injured spinal cord. Baroreceptors in the carotid sinus and the aorta sense the hypertension and stimulate the parasympathetic system. This results in a decrease in heart rate, but the visceral and peripheral vessels do not dilate because efferent impulses cannot pass through the cord lesion.

X-rays and a CT scan reveal that C.R. has a vertebral fracture at C8 with several bone fragments, but the right arm, shoulder, and leg are not fractured. Although the spinal cord is intact, neurologically it appears as if it is severed because of the process of autodestruction. Select the conditions that are involved in necrotic destruction of the cord. There are 5 correct answers. Hemorrhage Infection Vasospasm Histamine Norepinephrine, serotonin, and dopamine Edema Hypoxia Hyperthermia

hemorrhage vasospasm Norepinephrine, serotonin, and dopamine Edema Hypoxia

C.R. is to be discharged to a rehabilitation facility. He frequently asks what function he will regain with rehabilitation and if he will be able to work. You tell him that recovery is lengthy and that he may want to retrain for work other than construction, but he can live a meaningful life. You recognize that with a C8 lesion his highest level of function could be the ability to independently use a wheelchair, perform most self-care, and drive a car with powered hand controls. assist with transfer and self-care, feed himself with hand devices, and push a wheelchair on flat surfaces. independently use a wheelchair, use a full body brace for standing exercises, and drive a car with hand controls. drive an electric wheelchair with mobile hand supports, use powered hand splints, and feed self with setup and adaptive equipment.

independently use a wheelchair, perform most self-care, and drive a car with powered hand controls. A patient with a C7-8 injury has triceps to elbow extension and flexion, finger extension and flexion, and a good grasp with some decreased strength. Although a C8 injury is classified as a tetraplegia, it is the lowest cervical injury, and use of the arms and hands is possible.

You continue to monitor C.R.'s neurologic status for progressive cord compression, knowing that edema may extend the damage to the cord. Findings that would indicate extension above the level of his injury would include urinary retention. gastric distention. loss of grip strength. decrease in respiratory rate.

loss of grip strength. At a C8 injury, finger extension and flexion provide for good grasp, but upward extension would cause loss of finger function with a loss of grip strength. Respiratory depth would decrease with upward extension, but rate would increase to compensate for the hypoventilation. Urinary retention and gastric distention are already present as a result of vagus (parasympathetic) nerve domination of organs below the level of the injury.

1. What information would the nurse seek from a patient with newly diagnosed trigeminal neuralgia? a. Visual problems caused by ptosis. b. Poor appetite caused by loss of taste. c. Triggers leading to facial discomfort. d. Weakness on the affected side of the face.

ANS: C The major clinical manifestation of trigeminal neuralgia is severe facial pain triggered by cutaneous stimulation of the nerve. Ptosis, loss of taste, and facial weakness are not characteristics of trigeminal neuralgia.

You determine that C.R. is in neurogenic shock in addition to spinal shock. The three findings in his initial assessment that indicate neurogenic shock are hypotension; warm, dry skin; and ________________ Question: These signs of neurogenic shock occur as a result of the loss of function of part of the nervous system.

bradycardia sympathetic

SHORT ANSWER 1. A patient with neurogenic shock after a spinal cord injury is to receive lactated Ringer's solution 400 mL over 20 minutes. When setting the IV pump to deliver the IV fluid, the nurse should set the rate at how many milliliters per hour?

ANS: 1200 To administer 400 mL in 20 minutes, the nurse will need to set the pump to run at 1200 mL/hr.

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

ANS: D, C, B, A, E The first action should be to prevent further injury by stabilizing the patient's spinal cord if the patient does not have penetrating trauma. Maintenance of oxygenation by administration of 100% O2 is the second priority. Because neurogenic shock is a possible complication, monitoring of heart rhythm and BP are indicated followed by infusing normal saline for volume replacement. A CT scan to determine the extent and level of injury is needed once initial assessment and stabilization are accomplished.

9. A patient hospitalized with a new diagnosis of Guillain-Barré syndrome has numbness and weakness of both feet. Which intervention should the nurse anticipate? a. Infusion of immunoglobulin b. Administration of corticosteroids c. Intubation and mechanical ventilation d. Insertion of a nasogastric (NG) feeding tube

ANS: A Because 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 enteral nutrition may be used later in the progression of the syndrome but are not needed now. Corticosteroids are not helpful in reducing the duration or symptoms of the syndrome.

27. Which action should the nurse include in the plan of care for a patient who has cauda equina syndrome related to spinal cord injury? a. Catheterize patient every 3 to 4 hours. b. Assist patient to ambulate 4 times daily. c. Administer medications to reduce bladder spasm. d. Stabilize the neck when repositioning the patient.

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

18. A patient is admitted with possible botulism poisoning after eating home-canned green beans. Which intervention ordered by the health care provider should the nurse question? a. Encourage oral fluids to 3 L/day. b. Document neurologic symptoms. c. Position patient lying on the side. d. Observe respiratory status closely.

ANS: A The patient should be maintained NPO because neuromuscular weakness increases risk for aspiration. Side-lying position is not contraindicated. Assessment of neurologic and respiratory status is appropriate.

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

ANS: A 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.

A patient with suspected neurogenic shock after a diving accident has arrived in the emergency department. A cervical collar is in place. Which actions should the nurse take? (Select all that apply.) a. Prepare to administer atropine IV. b. Obtain baseline body temperature. c. Infuse large volumes of lactated Ringer's solution. d. Provide high-flow O2 (100%) by nonrebreather mask. e. Prepare for emergent intubation and mechanical ventilation.

ANS: A, B, D, E All the actions are appropriate except to give large volumes of lactated Ringer's solution. The patient with neurogenic shock usually has a normal blood volume, and it is important not to volume overload the patient. In addition, lactated Ringer's solution is used cautiously in all shock situations because an ischemic liver cannot convert lactate to bicarbonate.

MULTIPLE RESPONSE 1. Which collaborative and nursing actions should the nurse include in the plan of care for a patient who experienced a T2 spinal cord transection 24 hours ago? (Select all that apply.) a. Urinary catheter care b. Nasogastric (NG) tube feeding c. Continuous cardiac monitoring d. Administration of H2 receptor blockers e. Maintenance of a warm room temperature

ANS: A, C, D, E The patient is at risk for bradycardia and poikilothermia caused by sympathetic nervous system dysfunction and should have continuous cardiac monitoring and maintenance of a relatively warm room temperature. 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. Gastrointestinal motility is decreased initially, and NG suctioning is indicated.

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

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

19. Which action should the nurse recognize has the highest priority for a patient who was admitted 16 hours earlier with a C5 spinal cord injury? a. Cardiac monitoring for bradycardia b. Assessment of respiratory rate and effort c. Administration of low-molecular-weight heparin d. Application of pneumatic compression devices to legs

ANS: B 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 also are appropriate for preventing deterioration or complications but are not as important as assessment of respiratory effort.

10. A construction worker arrives at an urgent care center with a deep puncture wound from a rusty nail. The patient reports having had a tetanus booster 6 years ago. What intervention should the nurse anticipate? a. IV infusion of tetanus immune globulin (TIG) b. Administration of the tetanus-diphtheria (Td) booster c. Intradermal injection of an immune globulin test dose d. Initiation of the tetanus-diphtheria immunization series

ANS: B If the patient has not been immunized in the past 5 years, administration of the Td booster is indicated because the wound is deep. Immune globulin administration is given by the IM route if the patient has no previous immunization. Administration of a series of immunization is not indicated. TIG is not indicated for this patient, and a test dose is not needed for immune globulin.

2. Which patient assessment would help the nurse identify potential complications of 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.

ANS: B Oral hygiene is frequently neglected because of fear of triggering facial pain and may lead to gum disease, dental caries, or an abscess. Having the patient clench the facial muscles will not be useful because the sensory branches (rather than motor branches) of the nerve are affected by trigeminal neuralgia. Light touch and palpation may be triggers for pain and should be avoided.

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

ANS: B The new symptoms indicate spinal cord compression, an emergency that requires rapid treatment to avoid permanent loss of function. The other patient assessments also need nursing action but do not require intervention as rapidly as the new-onset weakness.

15. What should the nurse include in a rehabilitation plan as an appropriate goal for a 30-yr-old patient with a C6 spinal cord injury? a. Drive a car with powered hand controls. b. Propel a manual wheelchair on a flat surface. c. Turn and reposition independently when in bed. d. Transfer independently to and from a wheelchair.

ANS: B The patient with a C6 injury will be able to use the hands to push a wheelchair on flat, smooth s+A222urfaces. 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.

30. A patient with a T4 spinal cord injury asks the nurse if he will be able to be sexually active. Which information should the nurse include in an initial response? 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.

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

After change-of-shift report in the progressive care unit, who should the nurse care for first? a. Patient who had an inferior myocardial infarction 2 days ago and has crackles in the lung bases. b. Patient who had a T5 spinal cord injury 1 week ago and currently has a heart rate of 54 beats/min. c. Patient with suspected urosepsis who has new prescriptions for urine and blood cultures and antibiotics. d. Patient admitted with anaphylaxis 3 hours ago who has clear lung sounds and a blood pressure of 108/58 mm Hg.

ANS: C Antibiotics should be given within the first hour for patients who have sepsis or suspected sepsis to prevent progression to systemic inflammatory response syndrome and septic shock. The data on the other patients indicate that they are more stable. Crackles heard only at the lung bases do not need immediate intervention in a patient who has had a myocardial infarction. Mild bradycardia does not usually need treatment in patients with a spinal cord injury. The findings for the patient admitted with anaphylaxis show resolution of bronchospasm and hypotension.

22. A patient who had a C7 spinal cord injury 1 week ago has a weak cough effort and crackles. What initial intervention should the nurse perform? a. Suction the patient's nasopharynx. b. Notify the patient's health care provider. c. Push upward on the epigastric area as the patient coughs. d. Encourage incentive spirometry every 2 hours during the day.

ANS: C Because the cough effort is poor, the initial action should be to use assisted coughing techniques to improve the patient's ability to mobilize 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. The health care provider should be notified if airway clearance interventions are not effective or additional collaborative interventions are needed.

20. A patient is hospitalized with new onset of Guillain-Barré syndrome. What should the nurse recognize as the most essential assessment to complete? a. Determining level of consciousness b. Checking strength of the extremities c. Observing respiratory rate and effort d. Monitoring the cardiac rate and rhythm

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

25. Which nursing action for a patient with Guillain-Barré syndrome should the nurse identify as appropriate to delegate to experienced unlicensed assistive personnel (UAP)? a. Instilling artificial tears b. Assessing for bladder distention c. Administering bolus enteral nutrition d. Performing passive range of motion to extremities

ANS: D Assisting a patient with movement is included in UAP education and scope of practice. Administration of enteral nutrition, administration of ordered medications, and assessment are skills requiring more education and expanded scope of practice, and the RN should perform these skills.

5. The nurse identifies a patient with type 1 diabetes and a history of herpes simplex infection as being at risk for Bell's palsy. Which information should the nurse include in teaching the patient? a. "You may be able to prevent Bell's palsy by doing facial exercises regularly." b. "Prophylactic treatment of herpes with antiviral agents prevents Bell's palsy." c. "Medications to treat Bell's palsy work only if started before paralysis onset." d. "Call the doctor if you experience pain or develop herpes lesions near the ear."

ANS: D 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.

C.R.'s initial presentation indicates that he is in spinal shock. An additional finding that indicates spinal shock is Inability to cough. reflex emptying of the bladder. hyperreflexia below the level of the injury. decreased reflexes below the level of the injury.

decreased reflexes below the level of the injury. About 50% of people with acute spinal cord injury experience a temporary neurologic syndrome known as spinal shock. This type of shock is characterized by decreased reflexes, loss of sensation, and flaccid paralysis below the level of the injury. This syndrome lasts days to months and may mask postinjury neurologic function.

6. A patient with Bell's palsy refuses to eat while others are present because of embarrassment about drooling. What is the nurse's best response? a. Respect the patient's feelings and arrange for privacy at mealtimes. b. Teach the patient to chew food on the unaffected side of the mouth. c. Offer the patient liquid nutritional supplements at frequent intervals. d. Discuss the patient's concerns with visitors who arrive at mealtimes.

ANS: A The patient's desire for privacy should be respected to encourage adequate nutrition and reduce patient embarrassment. Liquid supplements may help maintain nutrition but 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.

The nurse performs discharge teaching for a 34-yr-old male patient with a thoracic spinal cord injury (T2) from a construction accident. Which statement indicates the patient understands teaching about autonomic dysreflexia? "I will perform self-catheterization at least 6 times per day." "A reflex erection may cause an unsafe drop in blood pressure." "If I develop a severe headache, I will lie down for 15 to 20 minutes." "I can avoid this problem by taking medications to prevent leg spasms."

Correct Answer: "I will perform self-catheterization at least 6 times per day." Rationale: Autonomic dysreflexia usually is caused by a distended bladder. Performing self-catheterization 5 or 6 times a day prevents bladder distention. Signs and symptoms of autonomic dysreflexia include a severe headache, hypertension, bradycardia, flushing, piloerection (goosebumps), and nasal congestion. Patients should raise the head of the bed to 45 to 90 degrees. This action helps to relieve hypertension (systolic pressure up to 300 mm Hg) that occurs with autonomic dysreflexia.

Which assessment finding would the nurse interpret as a manifestation of neurogenic shock in a patient with acute spinal cord injury? Bradycardia Hypertension Neurogenic spasticity Bounding pedal pulses

Correct Answer: Bradycardia Rationale: Neurogenic shock is caused by the loss of vasomotor tone after injury and is characterized by bradycardia and hypotension. Loss of sympathetic innervation causes peripheral vasodilation, venous pooling, and decreased cardiac output. Thus hypertension, neurogenic spasticity, and bounding pedal pulses are not seen in neurogenic shock.

When planning care for a patient with a cervical spinal cord injury (C5), which nursing problem has the highest priority? Constipation Difficulty coping Impaired breathing Impaired nutritional status

Correct Answer: Impaired breathing Rationale: Maintaining a patent airway is the most important goal for a patient with a cervical spinal cord injury. Respiratory needs are always the highest priority (ABCs).

Because C.R.'s cardiovascular status is unstable as a result of neurogenic shock, the health care provider decides to delay surgery a few days and allow edema to subside. In the emergency department, skull tongs and cervical traction are applied and he is admitted to the intensive care unit on a kinetic treatment bed. His abrasions are cleaned and covered with moist dressings. Measures initiated in the emergency department are continued. Select the appropriate nursing interventions for C.R. during the next 48 hours. There are 7 correct answers. Remove the tongs and clean the insertion sites on the skull twice a day. Inspect the skin over all areas at least q2hr. Encourage oral fluid intake to 2 to 4 L/day to maintain high volume dilute urine. Administer dopamine as prescribed to maintain normal heart rate. Assess the patient's ability to count to 10 aloud without taking a breath. Notify the physician if PaO2 is less than 60 mm Hg and if PaCO2 is greater than 45 mm Hg. Remove the weights from the traction twice a day while performing care to the tong sites. Use compression gradient stockings or pneumatic compression devices on the calves. Auscultate bowel sounds at least q4hr and monitor for abdominal distention. Maintain accurate intake and output records. Provide stimulation of vision, smell, and hearing to compensate for sensory deprivation.

Inspect the skin over all areas at least q2hr. Assess the patient's ability to count to 10 aloud without taking a breath. Notify the physician if PaO2 is less than 60 mm Hg and if PaCO2 is greater than 45 mm Hg. Use compression gradient stockings or pneumatic compression devices on the calves. Auscultate bowel sounds at least q4hr and monitor for abdominal distention. Maintain accurate intake and output records. Provide stimulation of vision, smell, and hearing to compensate for sensory deprivation.

Based on the most common cause of autonomic dysreflexia, prioritize the interventions you would take to manage C.R.'s complaints of headache and blurred vision Check the bladder for distention. Catheterize the bladder. Elevate the head of the bed. Take the blood pressure and pulse.

Take the blood pressure and pulse. Elevate the head of the bed. Check the bladder for distention. Catheterize the bladder.

The most common problem of children born with a myelomeningocele is: Test Bank - a. Neurogenic bladder. c. Respiratory compromise. b. Intellectual impairment. d. Cranioschisis.

a. Neurogenic bladder

A 15 year old is admitted to the intensive care unit (ICU) with a spinal cord injury. The MOST appropriate nursing interventions for this adolescent are: (Select all that apply.) Select all that apply. monitoring neurologic status. administering corticosteroids. monitoring for respiratory complications. discussing long-term care issues with the family. monitoring and maintaining hemodynamic status.

monitoring neurologic status. administering corticosteroids. monitoring for respiratory complications. monitoring and maintaining hemodynamic status. Close monitoring of sensory and motor function is important to prevent further deterioration of neurologic status as a result of spinal cord edema. Corticosteroids are administered to minimize the inflammation associated with the injury. Close monitoring of respiratory status for possible need of ventilator support. Remember "A-B-C's," airway, breathing, and circulation. Monitoring and maintaining hemodynamic status may require immediate attention related to increased intracranial pressure resulting in hypotension and bradycardia. The discussion of long-term care issues with the family is not appropriate in the acute phase of spinal cord injury.

When calling the rehabilitation facility to give report on C.R. before his transfer, you suggest to the receiving nurse that C.R. might benefit from a visit with recovered SCI patients who have adapted well to their physical limitations. This statement would be part of which component of SBAR communication?

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