n-clex level questions test 3 RNUR 1070

The nurse is working on a surgical floor. The nurse must log roll a male client following a: A. Laminectomy. B. Thoracotomy. C. Hemorrhoidectomy. D. Cystectomy.

A. Laminectomy. The client who has had spinal surgery, such as laminectomy, must be logrolled to keep the spinal column straight when turning. Laminectomy is among the most common procedures performed by spinal surgeons to decompress the spinal canal in various conditions. Preoperative and postoperative patient care is crucial to improve outcomes of laminectomy.

While in the ER, a client with C8 tetraplegia develops a blood pressure of 80/40, pulse 48, and RR of 18. The nurse suspects which of the following conditions? A. Autonomic dysreflexia B. Hemorrhagic shock C. Neurogenic shock D. Pulmonary embolism

C. Neurogenic shock Symptoms of neurogenic shock include hypotension, bradycardia, and warm, dry skin due to the loss of adrenergic stimulation below the level of the lesion. Neurogenic shock is a devastating consequence of spinal cord injury (SCI), also known as vasogenic shock. Injury to the spinal cord results in a sudden loss of sympathetic tone, which leads to the autonomic instability that is manifested in hypotension, bradyarrhythmia, and temperature dysregulation.

A 30-year-old was admitted to the progressive care unit with a C5 fracture from a motorcycle accident. Which of the following assessments would take priority? A. Bladder distension B. Neurological deficit C. Pulse ox readings D. The client's feelings about the injury

C. Pulse ox readings After a spinal cord injury, ascending cord edema may cause a higher level of injury. The diaphragm is innervated at the level of C4, so assessment of adequate oxygenation and ventilation is necessary. Maintain patent airway: keep head in neutral position, elevate head of bed slightly if tolerated, use airway adjuncts as indicated. Measure serial ABGs and pulse oximetry. Documents status of ventilation and oxygenation, identifies respiratory problems such as hypoventilation (low Pao2 and elevated Paco2) and pulmonary complications.

The nurse has given the male client with Bell's palsy instructions on preserving muscle tone in the face and preventing denervation. The nurse determines that the client needs additional information if the client states that he or she will: A. Wrinkle the forehead, blow out the cheeks, and whistle. B. Massage the face with a gentle upward motion. C. Perform facial exercises. D. Exposure to cold and drafts.

D. Exposure to cold and drafts. Exposure to cold or drafts is avoided. Local application of heat to the face may improve blood flow and provide comfort. Facial pain is controlled with analgesic agents or heat applied to the involved side of the face.

A nurse assesses a client who has episodes of autonomic dysreflexia. Which of the following conditions can cause autonomic dysreflexia? A. Headache B. Lumbar spinal cord injury C. Neurogenic shock D. Noxious stimuli

D. Noxious stimuli Noxious stimuli, such as a full bladder, fecal impaction, or a decubitus ulcer, may cause autonomic dysreflexia. Dysregulation of the autonomic nervous system leads to an uncoordinated autonomic response that may result in a potentially life-threatening hypertensive episode when there is a noxious stimulus below the level of the spinal cord injury. In about 85% of cases, this stimulus is from a urological source such as a UTI, a distended bladder, or a clogged Foley catheter.

A client with a C6 spinal injury would most likely have which of the following symptoms? A. Aphasia B. Hemiparesis C. Paraplegia D. Tetraplegia

D. Tetraplegia Tetraplegia occurs as a result of cervical spine injuries. Cervical injuries lead to the same deficits as thoracic injuries and, also, may result in loss of function of the upper extremities leading to tetraplegia. Injuries above C5 may also cause respiratory compromise due to loss of innervation of the diaphragm.

The nurse is caring for a client with a T5 complete spinal cord injury. Upon assessment, the nurse notes flushed skin, diaphoresis above the T5, and a blood pressure of 162/96. The client reports a severe, pounding headache. Which of the following nursing interventions would be appropriate for this client? Select all that apply. A. Elevate the HOB to 90 degrees. B. Loosen constrictive clothing. C. Use a fan to reduce diaphoresis. D. Assess for bladder distention and bowel impaction. E. Administer antihypertensive medication. F. Place the client in a supine position with legs elevated.

A, B, D, & E The client has signs and symptoms of autonomic dysreflexia. The potentially life-threatening condition is caused by an uninhibited response from the sympathetic nervous system resulting from a lack of control over the autonomic nervous system.

After falling 20', a 36-year-old man sustains a C6 fracture with spinal cord transaction. Which other findings should the nurse expect? A. Quadriplegia with gross arm movement and diaphragmatic breathing. B. Quadriplegia and loss of respiratory function. C. Paraplegia with intercostal muscle loss. D. Loss of bowel and bladder control.

A. Quadriplegia with gross arm movement and diaphragmatic breathing A client with a spinal cord injury at levels C5 to C6 has quadriplegia with gross arm movement and diaphragmatic breathing. Cervical spine injuries, although uncommon, can result in significant and long-term disability. The cervical spine encompasses seven vertebrae and serves as a protection to the spinal cord. C5 to C7 are responsible for deep tendon reflexes of the biceps, brachioradialis, and triceps respectively. C5 controls shoulder abduction with the aid of C4 and elbow flexion with the aid of C6. C6 to C7 are responsible for elbow extension, wrist extension, and flexion.

A male client with Bell's Palsy asks the nurse what has caused this problem. The nurse's response is based on an understanding that the cause is: A. Unknown, but possibly includes ischemia, viral infection, or an autoimmune problem. B. Unknown, but possibly includes long-term tissue malnutrition and cellular hypoxia. C. Primary genetic in origin, triggered by exposure to meningitis. D. Primarily genetic in origin, triggered by exposure to neurotoxins.

A. Unknown, but possibly includes ischemia, viral infection, or an autoimmune problem Bell's palsy is a one-sided facial paralysis from compression of the facial nerve. The exact cause is unknown but may include vascular ischemia, infection, exposure to viruses such as herpes zoster or herpes simplex, autoimmune disease, or a combination of these factors. BP is thought to result from compression of the seventh cranial nerve at the geniculate ganglion. The first portion of the facial canal, the labyrinthine segment, is the narrowest and it is here that most cases of compression occur. Due to the narrow opening of the facial canal, inflammation causes compression and ischemia of the nerve.

he nurse is caring for a client who suffered a spinal cord injury 48 hours ago. The nurse monitors for GI complications by assessing for: A. A flattened abdomen. B. Hematest positive nasogastric tube drainage. C. Hyperactive bowel sounds. D. A history of diarrhea.

B. Hematest positive nasogastric tube drainage . Development of a stress ulcer can be detected by hematest positive NG tube aspirate or stool. Gastrointestinal dysfunction including constipation, straining, diarrhea, distention, abdominal pain, incontinence, rectal bleeding, hemorrhoids, and autonomic dysreflexia during bowel movements occur in 27% to 62% of individuals with a spinal cord injury. During the acute stage of spinal cord injury there is an increased risk of gastrointestinal complications within the first few days post injury, including gastrointestinal hemorrhage, perforation, and paralytic ileus, while neurogenic bowel, affecting almost half of those with a spinal cord injury (46.9%) is a major problem long term both in terms of physical and psychological well being.

A client with C7 quadriplegia is flushed and anxious and complains of a pounding headache. Which of the following symptoms would also be anticipated? A. Decreased urine output or oliguria B. Hypertension and bradycardia C. Respiratory depression D. Symptoms of shock

B. Hypertension and bradycardia Hypertension, bradycardia, anxiety, blurred vision, and flushing above the lesion occur with autonomic dysreflexia due to uninhibited sympathetic nervous system discharge. The other options are incorrect. C5 to C7 are responsible for deep tendon reflexes of the biceps, brachioradialis, and triceps respectively. C5 controls shoulder abduction with the aid of C4 and elbow flexion with the aid of C6. C6 to C7 are responsible for elbow extension, wrist extension, and flexion.

A male client is admitted with a cervical spine injury sustained during a diving accident. When planning this client's care, the nurse should assign the highest priority to which nursing diagnosis? A. Impaired physical mobility B. Ineffective breathing pattern C. Disturbed sensory perception (tactile) D. Self-care deficit: Dressing/grooming

B. Ineffective breathing pattern Because a cervical spine injury can cause respiratory distress, the nurse should take immediate action to maintain a patent airway and provide adequate oxygenation. Maintain patent airway: keep head in neutral position, elevate head of bed slightly if tolerated, use airway adjuncts as indicated. Patients with high cervical injury and impaired gag and cough reflexes require assistance in preventing aspiration and maintaining patient airway.

A client with a spinal cord injury is prone to experiencing autonomic dysreflexia. The nurse would avoid which of the following measures to minimize the risk of recurrence? A. Strict adherence to a bowel retraining program. B. Limiting bladder catheterization to once every 12 hours. C. Keeping the linen wrinkle-free under the client. D. Preventing unnecessary pressure on the lower limbs.

B. Limiting bladder catheterization to once every 12 hours. The most frequent cause of autonomic dysreflexia is a distended bladder. Straight catheterization should be done every 4 to 6 hours, and Foley catheters should be checked frequently to prevent kinks in the tubing. Eliminate causative stimulus as able such as bladder, bowel, skin pressure (including loosening tight leg bands or clothing, removing abdominal binder or elastic stockings); temperature extremes.

Which of the following interventions describes an appropriate bladder program for a client in rehabilitation for spinal cord injury? A. Insert an indwelling urinary catheter to straight drainage. B. Schedule intermittent catheterization every 2 to 4 hours. C. Perform a straight catheterization every 8 hours while awake. D. Perform Crede's maneuver to the lower abdomen before the client voids.

B. Schedule intermittent catheterization every 2 to 4 hours. Intermittent catheterization should begin every 2 to 4 hours early in the treatment. When residual volume is less than 400 ml, the schedule may advance to every 4 to 6 hours. Begin bladder retraining per protocol when appropriate (fluids between certain hours, digital stimulation of trigger area, contraction of abdominal muscles, Credé's maneuver).

Which of the following conditions indicates that spinal shock is resolving in a client with C7 quadriplegia? A. Absence of pain sensation in chest B. Spasticity C. Spontaneous respirations D. Urinary continence

B. Spasticity Spasticity, the return of reflexes, is a sign of resolving shock. Spinal or neurogenic shock is characterized by hypotension, bradycardia, dry skin, flaccid paralysis, or the absence of reflexes below the level of injury. Spinal shock is a result of severe spinal cord injury. It usually requires high-impact, direct trauma that leads to spinal cord injury and spinal shock. The initial encounter with a patient that has spinal shock is usually under a trauma scenario.

Which of the following clients on the rehab unit is most likely to develop autonomic dysreflexia? A. A client with a brain injury. B. A client with a herniated nucleus pulposus. C. A client with a high cervical spine injury. D. A client with a stroke.

C. A client with a high cervical spine injury. Autonomic dysreflexia refers to uninhibited sympathetic outflow in clients with spinal cord injuries about the level of T10. The other clients aren't prone to dysreflexia. The etiology is a spinal cord injury, usually above the T6 level. It is unlikely to occur if the level is below T10. The higher the injury level, the greater the severity of the cardiovascular dysfunction. The severity and frequency of autonomic dysreflexia episodes are also associated with the completeness of the spinal cord injury

A 20-year-old client who fell approximately 30' is unresponsive and breathless. A cervical spine injury is suspected. How should the first-responder open the client's airway for rescue breathing? A. By inserting a nasopharyngeal airway. B. By inserting an oropharyngeal airway. C. By performing a jaw thrust maneuver. D. By performing the head-tilt, chin-lift maneuver.

C. By performing a jaw thrust maneuver. If the client has a suspected cervical spine injury, a jaw-thrust maneuver should be used to open the airway. Maintain patent airway: keep head in neutral position, elevate head of bed slightly if tolerated, use airway adjuncts as indicated. Patients with high cervical injury and impaired gag and cough reflexes require assistance in preventing aspiration and maintaining patient airway

The nurse is evaluating neurological signs of the male client in spinal shock following spinal cord injury. Which of the following observations by the nurse indicates that spinal shock persists? A. Positive reflexes B. Hyperreflexia C. Inability to elicit a Babinski's reflex. D. Reflex emptying of the bladder.

C. Inability to elicit a Babinski's reflex. Resolution of spinal shock is occurring when there is a return of reflexes (especially flexors to noxious cutaneous stimuli), a state of hyperreflexia rather than flaccidity, reflex emptying of the bladder, and a positive Babinski's reflex. It is more appropriate to use the trauma activation code announced when a patient with spinal shock arrives at the emergency department, that way the trauma team can complete a full workup for the patient. The full spinal examination should include motor, sensory reflexes including bulbocavernosus reflex and anal wink reflex.

The nurse is planning care for the client in spinal shock. Which of the following actions would be least helpful in minimizing the effects of vasodilation below the level of the injury? A. Monitoring vital signs before and during position changes. B. Using vasopressor medications as prescribed. C. Moving the client quickly as one unit. D. Applying Teds or compression stockings.

C. Moving the client quickly as one unit. Reflex vasodilation below the level of the spinal cord injury places the client at risk for orthostatic hypotension, which may be profound. Immobilize the patient. A sandbag and tape are not sufficient. Spinal immobilization in patients with penetrating trauma is not recommended. Patients with spinal cord injury need to be evaluated in a timely fashion to minimize secondary injuries. Preferably, these patients should be evaluated at level one trauma centers due to the extent of injuries.

A client with a T1 spinal cord injury arrives at the emergency department with a BP of 82/40, pulse 34, dry skin, and flaccid paralysis of the lower extremities. Which of the following conditions would most likely be suspected? A. Autonomic dysreflexia B. Hypervolemia C. Neurogenic shock D. Sepsis

C. Neurogenic shock Loss of sympathetic control and unopposed vagal stimulation below the level of injury typically cause hypotension, bradycardia, pallor, flaccid paralysis, and warm, dry skin in the client in neurogenic shock. Neurogenic shock is a devastating consequence of spinal cord injury (SCI), also known as vasogenic shock. Injury to the spinal cord results in a sudden loss of sympathetic tone, which leads to the autonomic instability that is manifested in hypotension, bradyarrhythmia, and temperature dysregulation.

A client is admitted to the emergency room with a spinal cord injury. The client is complaining of lightheadedness, flushed skin above the level of the injury, and headache. The client's blood pressure is 160/90 mm Hg. Which of the following is a priority action for the nurse to take? A. Loosen tight clothing or accessories B. Assess for any bladder distention C. Raise the head of the bed D. Administer antihypertensive

C. Raise the head of the bed The client is experiencing an autonomic dysreflexia, a life-threatening medical emergency that affects individuals with spinal injuries. Usually an individual with SCI has a blood pressure reading of 20 mm to 40 mm Hg above baseline. If this condition is suspected, the priority nursing action is to raise the head of bed or place the client in high Fowler's position. This promotes adequate ventilation and prevents the occurrence of hypertensive stroke.

A client is admitted with a spinal cord injury at the level of T12. He has limited movement of his upper extremities. Which of the following medications would be used to control edema of the spinal cord? A. acetazolamide (Diamox) B. furosemide (Lasix) C. methylprednisolone (Solu-Medrol) D. sodium bicarbonate

C. methylprednisolone (Solu-Medrol) High doses of Solu-Medrol are used within 24 hours of spinal injury to reduce cord swelling and limit neurological deficit. The other drugs aren't indicated in this circumstance. Methylprednisolone and its derivatives, methylprednisolone acetate succinate, and methylprednisolone sodium, are intermediate-acting, synthetic glucocorticoids used mainly as anti-inflammatory or immunosuppressive agents. Methylprednisolone is five times more potent in its anti-inflammatory properties relative to hydrocortisone (cortisol), with minimal mineralocorticoid activities compared to the latter.

The nurse is caring for a client admitted with spinal cord injury. The nurse minimizes the risk of compounding the injury most effectively by: A. Keeping the client on a stretcher. B. Logrolling the client on a firm mattress. C. Logrolling the client on a soft mattress. D. Placing the client on a Stryker frame.

D. Placing the client on a Stryker frame. Spinal immobilization is necessary after spinal cord injury to prevent further damage and insult to the spinal cord. Whenever possible, the client is placed on a Stryker frame, which allows the nurse to turn the client to prevent complications of immobility, while maintaining alignment of the spine. If a Stryker frame is not available, a firm mattress with a bed board should be used.

A male client has an impairment of cranial nerve II. Specific to this impairment, the nurse would plan to do which of the following to ensure the client to ensure client safety? A. Speak loudly to the client. B. Test the temperature of the shower water. C. Check the temperature of the food on the delivery tray. D. Provide a clear path for ambulation without obstacles.

D. Provide a clear path for ambulation without obstacles Cranial nerve II is the optic nerve, which governs vision. The nurse can provide safety for the visually impaired client by clearing the path of obstacles when ambulating. Compromise of the optic nerve results in visual field defects and/or visual loss. The type of visual field defect depends on which region of the optic pathway is disrupted.

During an episode of autonomic dysreflexia in which the client becomes hypertensive, the nurse should perform which of the following interventions? A. Elevate the client's legs. B. Put the client flat in bed. C. Put the client in Trendelenburg's position. D. Put the client in the high-Fowler's position

D. Put the client in the high-Fowler's position. Putting the client in the high-Fowler's position will decrease cerebral blood flow, decreasing hypertension. Sitting the patient upright and removing any tight clothing or constrictive devices will orthostatically help lower blood pressure by inducing pooling of blood in the abdominal and lower extremity vessels as well as removing any possible stimuli.

A 22-year-old client with quadriplegia is apprehensive and flushed, with a blood pressure of 210/100 and a heart rate of 50 bpm. Which of the following nursing interventions should be done first? A. Place the client flat in bed. B. Assess patency of the indwelling urinary catheter. C. Give one SL nitroglycerin tablet. D. Raise the head of the bed immediately to 90 degrees.

D. Raise the head of the bed immediately to 90 degrees. Anxiety, flushing above the level of the lesion, piloerection, hypertension, and bradycardia are symptoms of autonomic dysreflexia, typically caused by such noxious stimuli such as a full bladder, fecal impaction, or decubitus ulcer. Elevate head of bed to 45-degree angle or place patient in sitting position. Lowers BP to prevent intracranial hemorrhage, seizures, or even death. Note: Placing tetraplegic in sitting position automatically lowers BP.

A client has a cervical spine injury at the level of C5. Which of the following conditions would the nurse anticipate during the acute phase?A. Absent corneal reflex. A. Absent corneal reflex. B. Decerebrate posturing. C. Movement of only the right or left half of the body. D. The need for mechanical ventilation.

D. The need for mechanical ventilation The diaphragm is stimulated by nerves at the level of C4. Initially, this client may need mechanical ventilation due to cord edema. This may resolve in time. C3 to C4 contribute to breathing by controlling the muscles of the diaphragm. Patients with an injury in this area of the cervical spine can complain of difficulty breathing.