CHAPTER 43: CARE OF PATIENTS WITH PROBLEMS OF THE CENTRAL NERVOUS SYSTEM: THE SPINAL CORD

3. A client who has a herniated disk is being discharged after a percutaneous endoscopic discectomy. Which postprocedure instructions does the nurse provide before discharge? a. "You should begin an exercise routine which includes walking every day." b. "You must sleep in a supine position until the bandage is removed." c. "You may feel numbness or tingling in the legs for 24 hours." d. "You will need to wear a lumbar brace for 1 week."

ANS: A After this minimally invasive surgery, clients typically go home the same day or the day after surgery. Clients should be taught to begin the prescribed exercise program immediately after discharge, which includes walking every day. The client should not be restricted to one sleeping position. Clients generally have less pain with this procedure and do not experience numbness or tingling. The client may have a clear or gauze dressing but will not need to wear a lumbar brace.

1. The nurse is providing health education at a community center. Which instruction does the nurse include as part of client education for the prevention of low back pain? a. "Participate in a regular exercise program." b. "Purchase a soft mattress for sleeping comfort." c. "Wear high-heeled shoes only for special occasions." d. "Keep your weight within 20% of your ideal body weight."

ANS: A Exercise can strengthen back muscles, reducing the incidence of low back pain. The other options will not prevent low back pain.

16. The nurse is teaching a client who has a spinal cord injury how to prevent respiratory problems at home. Which statement indicates that the client correctly understands the teaching? a. "I will use my incentive spirometer every 2 hours while I'm awake." b. "I will not drink thick fluids to prevent choking." c. "I will take cough medicine to prevent excessive coughing." d. "I will position myself on my right side so I don't aspirate."

ANS: A Often, the person with a spinal cord injury will have weak intercostal muscles and is at higher risk for developing atelectasis and stasis pneumonia. Using an incentive spirometer every 2 hours helps the client expand her or his lungs more fully and prevents atelectasis. Clients should drink fluids that they can tolerate; usually thick fluids are easy to tolerate. The client should be encouraged to cough and clear secretions. Clients should be placed in high Fowler's position to prevent aspiration.

7. A client who suffered a spinal cord injury at level T5 several months ago develops a flushed face and blurred vision. On taking vital signs, the nurse notes the blood pressure to be 184/95 mm Hg. Which is the nurse's first action? a. Palpate the area over the bladder for distention. b. Place the client in the Trendelenburg position. c. Administer oxygen via a nasal cannula. d. Perform bilateral carotid massage.

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

28. The nurse is assessing a client's coping strategies after suffering a traumatic spinal cord injury. Which information related to this assessment is important for the nurse to obtain? (Select all that apply.) a. Spiritual or religious beliefs b. Level of pain c. Family support d. Level of independence e. Annual income f. Previous coping strategies

ANS: A, C, D, F Information about the client's preinjury psychosocial status, usual methods of coping with illness, difficult situations, and disappointments should be obtained. Determine the client's level of independence or dependence and his or her comfort level in discussing feelings and emotions with family members or close friends. Clients who are emotionally secure and have a positive self-image, a supportive family, and financial and job security often adapt to their injury. Information about the client's spiritual and religious beliefs or cultural background also assists the nurse in developing the plan of care. The other options do not supply as much information about coping.

6. The nurse is caring for a client who has undergone a spinal fusion. Which specific postoperative instructions does the nurse give this client? a. "You may lift items up to 10 pounds." b. "Wear your brace when you are out of bed." c. "You must remain on bedrest for 48 hours after surgery." d. "You will need to take steroids to prevent rejection of the bone graft."

ANS: B Clients who undergo spinal fusion are fitted with a brace that they need to wear throughout the healing process (usually 3 to 6 months) whenever they are out of bed. The client does not need to remain on bedrest for the first 48 hours, should not lift anything, and will not take steroids for rejection prevention.

11. The nurse is assessing a client with a spinal cord injury at the T5 level. Which clinical manifestation alerts the nurse to the presence of a complication of this injury? a. Rhinorrhea and epiphora b. Fever and cough c. Agitation and restlessness d. Hip and knee pain

ANS: B Clients with injuries at or above the T6 vertebra are especially at risk for respiratory complications caused by impaired intercostal muscles. The development of fever and cough should alert the nurse to the possibility of pneumonia. The other manifestations are not related to complications from this type of injury.

10. A client who experienced a spinal cord injury 1 hour ago is brought to the emergency department. Which prescribed medication does the nurse prepare to administer to this client? a. Intrathecal baclofen b. Methylprednisolone c. Atropine sulfate d. Epinephrine

ANS: B Methylprednisolone (Medrol) should be given within 8 hours of the injury. Clients who receive this therapy usually show improvement in motor and sensory function. The other medications are inappropriate for the client.

17. The nurse assesses for which clinical manifestation in a client with multiple sclerosis (MS) of the relapsing type? a. Absence of periods of remission b. Attacks becoming increasingly frequent c. Absence of active disease manifestations d. Gradual neurologic symptoms without remission

ANS: B The classic picture of relapsing-remitting MS is characterized by increasingly frequent attacks. The other manifestations do not correlate with a relapsing type of MS.

21. The nurse is preparing a client who has multiple sclerosis (MS) for discharge home from a rehabilitation center. The client has been prescribed cyclophosphamide and methylprednisolone Which instruction does the nurse include in the teaching plan for the client? a. "Take warm baths to promote muscle relaxation." b. "Avoid crowds and people with colds." c. "Use physical aids such as walkers as little as possible." d. "Stop using these medications when your symptoms improve."

ANS: B The client should be taught to avoid people with any type of upper respiratory illness because these medications are immunosuppressive. Warm baths will exacerbate the MS symptoms, assistive devices may be required for safe ambulation, and medication should not be stopped.

29. The nurse is teaching a client with a spinal cord tumor about the treatment plan. Which statements indicate that the client correctly understands the teaching? (Select all that apply.) a. "Because my symptoms occurred so quickly, I am likely to be cured quickly by surgery." b. "Radiation therapy can shrink the tumor but radiation can cause more problems, too." c. "I am glad you are here to turn me. Lying in one position for a long time makes my pain worse, even if turning is uncomfortable." d. "I have put my affairs in order and purchased a burial plot because this type of cancer is almost always fatal." e. "My family is making some changes at home for me, including moving my bedroom downstairs."

ANS: B, C, E Although surgery may relieve symptoms by reducing pressure on the spine and debulking the tumor, some motor and sensory deficits may remain. Spinal tumors usually cause disability but are not usually fatal.

30. The nurse is teaching a male client with a spinal cord injury at T4 (thoracic) about the sexual effects of this injury. Which statement by the client indicates correct understanding of the teaching? (Select all that apply.) a. "I will not be able to have an erection because of my injury." b. "Ejaculation may not be as predictable as before." c. "I will explore other ways besides intercourse to please my partner." d. "I may urinate with ejaculation but this will not cause an infection." e. "I should be able to have an erection with stimulation."

ANS: B, D, E Men with injuries above T6 often are able to have erections by stimulating reflex activity. For example, stroking the penis will cause an erection. Ejaculation is less predictable and may be mixed with urine. However, urine is sterile, so the client's partner will not get an infection.

23. Which neurologic test or procedure requires the nurse to determine whether an informed consent has been obtained from the client before the test or procedure? a. Measurement of sensation using the pinprick method b. Computed tomography of the cranial vault c. Lumbar puncture for cerebrospinal fluid (CSF) sampling d. Venipuncture for autoantibody analysis

ANS: C A lumbar puncture is an invasive procedure with many potentially serious complications. The other assessments or tests are considered noninvasive.

27. The nurse is discussing advanced directives with a client who has amyotrophic lateral sclerosis (ALS). The client states, "I do not want to be placed on a mechanical ventilator." How does the nurse respond? a. "You will need to discuss that with your family and health care provider." b. "Why are you afraid of being placed on a breathing machine?" c. "What would you like to be done if you begin to have difficulty breathing?" d. "You will be on the ventilator only until your muscles get stronger."

ANS: C ALS is an adult-onset upper and lower motor neuron disease, characterized by progressive weakness, muscle wasting, and spasticity, eventually leading to paralysis. Once muscles of breathing are involved, the client must include in the advance directives what is to be done when breathing is no longer possible without intervention. The other statements do not address the client's needs.

18. The nurse is assessing a client with an early onset of multiple sclerosis (MS). Which clinical manifestation does the nurse expect to see? a. Hyperresponsive reflexes b. Excessive somnolence c. Nystagmus d. Heat intolerance

ANS: C Early signs and symptoms of MS include changes in motor skills, vision, and sensation. The other manifestations are later signs of MS.

20. A client with multiple sclerosis is being treated with fingolimod . Which clinical manifestation alerts the nurse to an adverse effect of this medication? a. Periorbital edema b. Black tarry stools c. Bradycardia d. Vomiting after meals

ANS: C Fingolimod (Gilenya) is an antineoplastic agent that can cause bradycardia, especially within the first 6 hours after administration. The other manifestations are not adverse effects of fingolimod.

2. The nurse is caring for a client who has low back pain (LBP) from a work-related injury. Which measures does the nurse incorporate into the client's plan of care? a. Apply moist heat continuously to the affected area. b. Use ice packs or ice massage for 1 to 2 hours over the affected area. c. Apply heat packs for 20 to 30 minutes at least four times daily. d. Advise the client to avoid hot baths or showers.

ANS: C Heat increases blood flow to the affected area and promotes healing of injured nerves. However, continuous application of moist heat can promote skin breakdown.

15. A client with paraplegia is scheduled to participate in a rehabilitation program. The client states, "I do not understand the need for rehabilitation; the paralysis will not go away and it will not get better." How does the nurse respond? a. "If you do not want to participate in the rehabilitation program, I will cancel the order." b. "Your doctor has helped many clients with your injury and has ordered a rehabilitation program to help you." c. "The rehabilitation program will teach you how to maintain the functional ability you have and prevent further disability." d. "When new discoveries are made regarding paraplegia, people in rehabilitation programs will benefit first."

ANS: C Participation in rehabilitation programs has many purposes, including prevention of disability, maintenance of functional ability, and restoration of function. The other responses do not meet the client's needs.

12. The nurse notes reddened areas over the hips and sacrum of a client with paraplegia from a spinal cord injury. Which action does the nurse implement? a. Massage the reddened areas with a barrier cream. b. Perform hip flexion and extension range-of-motion (ROM) exercises. c. Reposition the client so that the reddened area does not bear weight. d. Ensure that the client sits in a chair at least once each shift.

ANS: C Reddened areas should not be rubbed because this action could cause more extensive damage to the already fragile capillary system. ROM exercises are used to prevent contractures. The reddened areas should be assessed for blanching. If the skin does not blanch, the area is vulnerable to breakdown. Appropriate interventions to relieve pressure on these areas through positioning, assistive devices, and skin protection should then be used.

25. The nurse is teaching a client who has an unstable thoracic vertebral fracture and is being treated with immobilization before surgery. Which statement does the nurse include in the client's teaching? a. "You will need to apply an immobilizing brace snugly around your waist when out of bed." b. "You will remain strapped to the transport back board until the surgical room is ready." c. "Keep your spine in alignment by not sitting up, arching your back, or twisting in bed." d. "An incentive spirometer will prevent you from having atelectasis and pneumonia after surgery."

ANS: C The client with a thoracic vertebral fracture is at risk for spinal cord injury, especially with flexion, extension, or rotation of the trunk. The client will be moved to a more comfortable bed to wait for surgery and will remain on bedrest. Although teaching about how to use an incentive spirometer is important for surgical clients, the incentive spirometer alone does not prevent atelectasis and pneumonia; it only assists the client to breathe deeply.

9. The nurse is caring for a client who has a vertebral fracture. Which intervention does the nurse implement to prevent deterioration of the client's neurologic status? a. Reorient the client to time, place, and person. b. Administer the Mini-Mental State Examination. c. Immobilize the affected portion of the spinal column. d. Reposition the client every 2 hours.

ANS: C The nurse keeps the client in optimal body alignment at all times, avoiding flexion and extension at the site of vertebral injury, to prevent further cord injury or irritability from bone fragments. A brace, traction, or external fixation may be used for this purpose. The other interventions would not prevent deterioration of the client's neurologic status. Assessments would assist with the recognition of neurologic changes but would not prevent them.

26. The nurse is planning care for a client who has a spinal cord injury. Which interdisciplinary team member does the nurse consult with to assist the client with activities of daily living? a. Social worker b. Physical therapist c. Occupational therapist d. Case manager

ANS: C The occupational therapist instructs the client in the correct use of all adaptive equipment. In collaboration with the therapists, the nurse instructs family members or the caregiver about transfer skills, feeding, bathing, dressing, positioning, and skin care. The other team members are consulted to assist the client with unrelated issues.

14. A client who has a lower motor neuron injury experiences a flaccid bowel elimination pattern. Which action does the nurse implement to assist in relieving this client's constipation? a. Pouring warm water over the perineum b. Tapping the abdomen from left to right c. Administering daily tap water enemas d. Implementing a consistent daily time for elimination

ANS: D For the client with a lower motor neuron injury, the resulting flaccid bowel may require a bowel program for the client, which includes stool softeners, increased fluid intake, a high-fiber diet, and a consistent elimination time. The other interventions do not assist this client.

22. Early manifestations of amyotrophic lateral sclerosis (ALS) and multiple sclerosis (MS) are somewhat similar. Which clinical feature of ALS distinguishes it from MS? a. Dysarthria b. Dysphagia c. Muscle weakness d. Impairment of respiratory muscles

ANS: D In ALS, progressive muscle atrophy occurs until a flaccid quadriplegia develops. Eventually, the respiratory muscles are involved, and this leads to respiratory compromise.

13. The nurse is caring for a client with a lower motor neuron lesion who wishes to achieve bladder control. Which intervention does the nurse implement to effectively stimulate the initiation of voiding for this client? a. Stroking the inner aspect of the thigh b. Intermittent catheterization c. Digital anal stimulation d. The Valsalva maneuver

ANS: D In clients with lower motor neuron problems, such as spinal cord injury, performing a Valsalva maneuver or tightening the abdominal muscles are interventions that can initiate voiding. The other interventions do not initiate voiding.

4. The nurse is assessing a client who had a discectomy 6 hours ago. Which client complaint requires priority action by the nurse? a. "I am feeling tired." b. "My mouth is so dry." c. "I can't seem to relax and rest." d. "I am unable to urinate."

ANS: D Inability to void may indicate damage to the sacral spinal nerves. The other symptoms require the nurse to provide care but are not the priority or a complication of the procedure.

24. A client is scheduled for magnetic resonance imaging (MRI). Which action does the nurse implement before the test? a. Ensure that the person does not eat for 8 hours before the procedure. b. Discontinue all neuroactive medications 3 hours before the procedure. c. Make sure that the client has an identification bracelet that cannot be removed. d. Replace the client's gown with metal snaps with one that has cloth ties.

ANS: D Metal objects are a hazard because of the magnetic field used in the MRI procedure. The other actions are not necessary for MRI.

19. A client presents with an acute exacerbation of multiple sclerosis. Which prescribed medication does the nurse prepare to administer? a. Baclofen b. Interferon beta-1b c. Dantrolene sodium d. Methylprednisolone

ANS: D Methylprednisolone (corticosteroids) is the drug of choice for acute exacerbations of the disease. The other medications are not appropriate.

5. The nurse is providing discharge teaching to a client after a lumbar laminectomy. For which complication does the nurse instruct the client to return to the hospital? a. Pain at the incision site b. Decreased appetite c. Slight redness and itching at the incision site d. Clear drainage from the incision site

ANS: D The finding of clear fluid on the dressing after a laminectomy strongly suggests a cerebrospinal fluid leak, which constitutes an emergency. The client has in increased risk of meningitis with a spinal fluid leak. Pain, redness, and itching at the site are normal. The client should be encouraged to eat a healthy diet but does not need to return to the hospital for a decreased appetite.

8. Emergency medical services arrive to the emergency department with a client who has a cervical spinal cord injury. Which priority assessment does the emergency department nurse perform at this time? a. Level of consciousness and orientation b. Heart rate and rhythm c. Muscle strength and reflexes d. Respiratory pattern and airway

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