SG Lewis Ch 61 Peripheral Nerve and Spinal Cord Problems

1. A patient is diagnosed with Bell's palsy. What information should the nurse teach the patient about Bell's palsy (select all that apply)? a. Bell's palsy affects the motor branches of the facial nerve. b. Antiseizure drugs are the drugs of choice for treatment of Bell's palsy. c. Nutrition and avoidance of hot foods or beverages are special needs of this patient. d. Herpes simplex virus 1 is strongly associated as a precipitating factor in the development of Bell's palsy. e. Moist heat, gentle massage, electrical stimulation of the nerve, and exercises are prescribed to treat Bell's palsy. f. An inability to close the eyelid, with an upward movement of the eyeball when closure is attempted, is evident.

1. a, d, e, f. Bell's palsy affects the motor branches of the facial nerve. It is treated with corticosteroids, usually prednisone. Herpes simplex virus 1 may be a precipitating factor. Moist heat, gentle massage, electrical nerve stimulation, and exercises are prescribed. Care must be taken to protect the eye with sunglasses, artificial tears or gel, and possibly taping the eyelid closed at night. Oral hygiene is important but avoidance of hot foods is not needed.

10. A 70-year-old patient is admitted after falling from his roof. He has a spinal cord injury at the C7 level. What findings during the assessment identify the presence of spinal shock? a. Paraplegia with a flaccid paralysis b. Tetraplegia with total sensory loss c. Total hemiplegia with sensory and motor loss d. Spastic tetraplegia with loss of pressure sensation

10. b. At the C7 level, spinal shock is manifested by tetraplegia and sensory loss. The neurologic loss may be temporary or permanent. Paraplegia with sensory loss would occur at the level of T1. A hemiplegia occurs with central (brain) lesions affecting motor neurons and spastic tetraplegia occurs when spinal shock resolves.

11. Which syndrome of incomplete spinal cord lesion is described as cord damage common in the cervical region resulting in greater weakness in upper extremities than lower? a. Central cord syndrome b. Anterior cord syndrome c. Posterior cord syndrome d. Cauda equina and conus medullaris syndromes

11. a. In central cord syndrome, motor weakness and sensory loss are present in both upper and lower extremities, with upper extremities affected more than lower extremities.

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

12. b. Brown-Séquard syndrome is characterized by ipsilateral loss of motor function and position and vibratory sense and vasomotor paralysis with contralateral loss of pain and temperature sensation below the level of the injury. Damage to the most distal cord and nerve roots with flaccid paralysis of the lower limbs and areflexic bowel and bladder is seen with cauda equine syndrome or conus medullaris syndrome. Posterior cord syndrome is rare, with cord damage resulting in loss of proprioception below the lesion level but retention of motor control and temperature and pain sensation. Anterior cord syndrome is often caused by flexion injury, with acute compression of the cord resulting in complete motor paralysis and loss of pain and temperature sensation below the level of injury but touch, position, vibration, and motion remaining intact.

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

13. c. The primary injury of the spinal cord rarely affects the entire cord but the pathophysiology of secondary injury may result in damage that is the same as mechanical severance of the cord. Complete cord dissolution occurs through autodestruction of the cord by hemorrhage, edema, and the presence of metabolites and norepinephrine, resulting in anoxia and infarction of the cord. Edema resulting from the inflammatory response may compress the spinal cord as well as increase the damage as it extends above and below the injury site.

14. A patient with a spinal cord injury has spinal shock. The nurse plans care for the patient based on what knowledge? a. Rehabilitation measures cannot be initiated until spinal shock has resolved. b. The patient will need continuous monitoring for hypotension, tachycardia, and hypoxemia. c. Resolution of spinal shock is manifested by spasticity, hyperreflexia, and reflex emptying of the bladder. d. The patient will have complete loss of motor and sensory functions below the level of the injury but autonomic functions are not affected.

14. c. Spinal shock occurs in about half of all people with acute spinal cord injury. In spinal shock, the entire cord below the level of the lesion fails to function, resulting in a flaccid paralysis and hypomotility of most processes without any reflex activity. Return of reflex activity, although hyperreflexive and spastic, signals the end of spinal shock. Rehabilitation activities are not contraindicated during spinal shock and should be instituted if the patient's cardiopulmonary status is stable. Neurogenic shock results from loss of vascular tone caused by the injury and is manifested by hypotension, peripheral vasodilation, and decreased cardiac output (CO). Sympathetic function is impaired below the level of the injury because sympathetic nerves leave the spinal cord at the thoracic and lumbar areas and cranial parasympathetic nerves predominate in control over respirations, heart, and all vessels and organs below the injury, which includes autonomic functions.

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

15. b. Until the edema and necrosis at the site of the injury are resolved in 72 hours to 1 week after the injury, it is not possible to determine how much cord damage is present from the initial injury, how much secondary injury occurred, or how much the cord was damaged by edema that extended above the level of the original injury. The return of reflexes signals only the end of spinal shock and the reflexes may be inappropriate and excessive, causing spasms that complicate rehabilitation.

16. Priority Decision: The patient was in a traffic collision and is experiencing loss of function below C4. Which effect must the nurse be aware of to provide priority care for the patient? a. Respiratory diaphragmatic breathing b. Loss of all respiratory muscle function c. Decreased response of the sympathetic nervous system d. GI hypomotility with paralytic ileus and gastric distention

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

17. A patient is admitted to the emergency department with a spinal cord injury at the level of T2. Which finding is of most concern to the nurse? a. SpO2 of 92% b. Heart rate of 42 bpm c. Blood pressure of 88/60 mm Hg d. Loss of motor and sensory function in arms and legs

17. b. Neurogenic shock associated with cord injuries above the level of T6 greatly decreases the effect of the sympathetic nervous system and bradycardia and hypotension occur. A heart rate of 42 bpm is not adequate to meet the oxygen needs of the body. While low, the blood pressure is not at a critical point. The oxygen saturation is satisfactory and the motor and sensory losses are expected.

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

18. c. With the injury at T4, the highest-level realistic goal for this patient is to be able to be independent in self-care and wheelchair use because arm function will not be affected. Indoor mobility in a manual wheelchair will be achievable but it is not the highest-level goal. Ambulating with crutches and leg braces can be achieved only by patients with injuries in T6-12 area. Independent ambulation with short leg braces and canes could occur for a patient with an L3-4 injury. (See Table 61-4.)

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

19. d. Although surgical treatment of spinal cord injuries often depends on the preference of the health care provider, surgery is usually indicated when there is continued compression of the cord by extrinsic forces or when there is evidence of cord compression. Other indications may include progressive neurologic deficit, compound fracture of the vertebra, bony fragments, and penetrating wounds of the cord.

2. Priority Decision: When planning care for the patient with trigeminal neuralgia, which patient outcome should the nurse set as the highest priority? a. Relief of pain b. Protection of the cornea c. Maintenance of nutrition d. Maintenance of positive body image

2. a. The pain of trigeminal neuralgia is excruciating and it may occur in clusters that continue for hours. The condition is considered benign with no major effects except the pain. Corneal exposure is a problem in Bell's palsy or it may occur following surgery for the treatment of trigeminal neuralgia. Maintenance of nutrition is important but not urgent because chewing may trigger trigeminal neuralgia and patients then avoid eating. Except during an attack, there is no change in facial appearance in a patient with trigeminal neuralgia and body image is more disturbed in response to the paralysis typical of Bell's palsy.

20. Priority Decision: A patient is admitted to the emergency department with a possible cervical spinal cord injury following an automobile crash. During admission of the patient, what is the highest priority for the nurse? a. Maintaining a patent airway b. Maintaining immobilization of the cervical spine c. Assessing the patient for head and other injuries d. Assessing the patient's motor and sensory function

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

21. Without surgical stabilization, what method of immobilization for the patient with a cervical spinal cord injury should the nurse expect to be used? a. Kinetic beds b. Hard cervical collar c. Skeletal traction with skull tongs d. Sternal-occipital-mandibular immobilizer brace

21. c. The development of better surgical stabilization has made surgery the more frequent treatment of cervical injuries. However, when surgery cannot be done, skeletal traction with the use of Crutchfield, Vinke, or other types of skull tongs is required to immobilize the cervical vertebrae, even if a fracture has not occurred. Hard cervical collars or a sternal-occipitalmandibular immobilizer brace may be used after cervical stabilization surgery or for minor injuries or stabilization during emergency transport of the patient. Sandbags may also be used temporarily to stabilize the neck during insertion of tongs or during diagnostic testing immediately following the injury. Special turning or kinetic beds may be used to turn and mobilize patients who are in cervical traction.

22. The health care provider has ordered IV dopamine (Intropin) for a patient in the emergency department with a spinal cord injury. The nurse determines that the drug is having the desired effect when what is observed in patient assessment? a. Heart rate of 68 bpm b. Respiratory rate of 24 c. Blood pressure of 106/82 mm Hg d. Temperature of 96.8°F (36.0°C)

22. c. Dopamine is a vasopressor that is used to maintain blood pressure during states of hypotension that occur during neurogenic shock associated with spinal cord injury. Atropine would be used to treat bradycardia. The temperature reflects some degree of poikilothermism but this is not treated with medications.

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

23. c. Because pneumonia and atelectasis are potential problems related to ineffective coughing and the loss of intercostal and abdominal muscle function, the nurse should assess the patient's breath sounds and respiratory function to determine whether secretions are being retained or whether there is progression of respiratory impairment. Suctioning is not indicated unless lung sounds indicate retained secretions. Position changes will help to mobilize secretions. Intubation and mechanical ventilation are used if the patient becomes exhausted from labored breathing or if arterial blood gases (ABGs) deteriorate.

24. Following a T2 spinal cord injury, the patient develops paralytic ileus. While this condition is present, what should the nurse anticipate that the patient will need? a. IV fluids b. Tube feedings c. Parenteral nutrition d. Nasogastric suctioning

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

25. How is urinary function maintained during the acute phase of spinal cord injury? a. An indwelling catheter b. Intermittent catheterization c. Insertion of a suprapubic catheter d. Use of incontinent pads to protect the skin

25. a. During the acute phase of spinal cord injury, the bladder is hypotonic, causing urinary retention with the risk for reflux into the kidney or rupture of the bladder. An indwelling catheter is used to keep the bladder empty and to monitor urinary output. Intermittent catheterization or other urinary drainage methods may be used in longterm bladder management. Use of incontinent pads is inappropriate because they do not help the bladder to empty

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

26. b. When spinal shock ends, reflex movement and spasms will occur, which may be mistaken for return of function; however, with the resolution of edema, some normal function may also occur. It is important when movement occurs to determine whether the movement is voluntary and can be consciously controlled, which would indicate some return of function.

27. Priority Decision: A patient with a spinal cord injury suddenly experiences a throbbing headache, flushed skin, and diaphoresis above the level of injury. After checking the patient's vital signs and finding a systolic blood pressure of 210 and a heart rate of 48 bpm, number the following nursing actions in order of priority from highest to lowest (begin with number 1 as first priority). _ _________ a. Administer ordered prn nifedipine (Procardia). __________ b. Check for bladder distention. __________ c. Document the occurrence, treatment, and response. __________ d. Place call to physician. __________ e. Raise the head of bed (HOB) to 45 degrees or above. __________ f. Loosen tight clothing on the patient.

27. a. 5; b. 2; c. 6; d. 3; e. 1; f. 4. The patient is experiencing autonomic dysreflexia. The initial response by the nurse should be to elevate the head of bed (HOB) to decrease blood pressure (BP) and then to remove noxious stimulation. Frequently the trigger is bladder distention, which can be dealt with quickly. The physician needs to be notified as soon as possible and, depending on the communication system available to the nurse, he or she should have the call placed. Meanwhile, the nurse should stay with the patient and loosen any restrictive clothing. The physician may order an antihypertensive and documentation should be an accurate and thorough description of the entire episode.

28. A patient with paraplegia has developed an irritable bladder with reflex emptying. What will be most helpful for the nurse to teach the patient? a. Hygiene care for an indwelling urinary catheter b. How to perform intermittent self-catheterization c. To empty the bladder with manual pelvic pressure in coordination with reflex voiding patterns d. That a urinary diversion, such as an ileal conduit, is the easiest way to handle urinary elimination

28. b. Intermittent self-catheterization five to six times a day is the recommended method of bladder management for the patient with a spinal cord injury and reflexic neurogenic bladder because it more closely mimics normal emptying and has less potential for infection. The patient and family should be taught the procedure using clean technique and if the patient has use of the arms, self-catheterization should be performed. Indwelling catheterization is used during the acute phase to prevent overdistention of the bladder and surgical urinary diversions are used if urinary complications occur.

29. In counseling patients with spinal cord lesions regarding sexual function, how should the nurse advise a male patient with a complete lower motor neuron lesion? a. He is most likely to have reflexogenic erections and may experience orgasm if ejaculation occurs. b. He may have uncontrolled reflex erections but orgasm and ejaculation are usually not possible. c. He has a lesion with the greatest possibility of successful psychogenic erection with ejaculation and orgasm. d. He will probably be unable to have either psychogenic or reflexogenic erections and no ejaculation or orgasm.

29. d. Most patients with a complete lower motor neuron lesion are unable to have either psychogenic or reflexogenic erections and alternative methods of obtaining sexual satisfaction may be suggested. Patients with incomplete lower motor neuron lesions have the highest possibility of successful psychogenic erections with ejaculation whereas patients with incomplete upper motor neuron lesions are more likely to experience reflexogenic erections with ejaculation. Patients with complete upper motor neuron lesions usually have only reflex sexual function with rare ejaculation.

3. Surgical intervention is being considered for a patient with trigeminal neuralgia. The nurse recognizes that which procedure has the least residual effects with a positive outcome? a. Glycerol rhizotomy b. Gamma knife radiosurgery c. Microvascular decompression d. Percutaneous radiofrequency rhizotomy

3. a. Although percutaneous radiofrequency rhizotomy and microvascular decompression provide the greatest relief of pain, glycerol rhizotomy causes less sensory loss and fewer sensory aberrations with comparable pain relief and less danger. Gamma knife radiosurgery provides precise high doses of radiation useful for persistent pain after other surgery.

30. During the patient's process of grieving for the losses resulting from spinal cord injury, what should the nurse do? a. Help the patient to understand that working through the grief will be a lifelong process. b. Assist the patient to move through all stages of the mourning process to acceptance. c. Let the patient know that anger directed at the staff or the family is not a positive coping mechanism. d. Facilitate the grieving process so that it is completed by the time the patient is discharged from rehabilitation.

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

31. A patient with a metastatic tumor of the spinal cord is scheduled for removal of the tumor by a laminectomy. In planning postoperative care for the patient, what should the nurse recognize? a. Most cord tumors cause autodestruction of the cord as in traumatic injuries. b. Metastatic tumors are commonly extradural lesions that are treated palliatively. c. Radiation therapy is routinely administered following surgery for all malignant spinal cord tumors. d. Because complete removal of intramedullary tumors is not possible, the surgery is considered palliative.

31. b. Most metastatic or secondary tumors are extradural lesions in which treatment, including surgery, is palliative. Primary spinal tumors may be removed with the goal of cure. Most tumors of the spinal cord are slow-growing, do not cause autodestruction, and, if removal is possible, can have complete function restored. Radiation is used to treat metastatic tumors that are sensitive to radiation and that have caused only minor neurologic deficits in the patient. Radiation is also used as adjuvant therapy to surgery for intramedullary tumors.

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

4. c. Because attacks of trigeminal neuralgia may be precipitated by hot or cold air movement on the face, jarring movements, or talking, the environment should be of moderate temperature and free of drafts and patients should not be expected to converse during the acute period. Patients often prefer to carry out their own care because they are afraid someone else may inadvertently injure them or precipitate an attack. The nurse should stress that oral hygiene be performed because patients often avoid it but residual food in the mouth after eating occurs more frequently with Bell's palsy.

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

5. a. The most serious complication of Guillain-Barré syndrome is respiratory failure and it is essential that respiratory rate and depth and vital capacity are monitored to detect involvement of the autonomic nerves that affect respiration. Corticosteroids may be used in treatment but do not appear to have an effect on the prognosis or duration of the disease. Rather, plasmapheresis or administration of high-dose immunoglobulin does result in shortening recovery time. The peripheral nerves of both the sympathetic and the parasympathetic nervous systems are involved in the disease and may lead to orthostatic hypotension, hypertension, and abnormal vagal responses affecting the heart. Guillain-Barré syndrome may affect the lower brainstem and cranial nerves (CNs) VII, VI, III, XII, V, and X, affecting facial, eye, and swallowing functions.

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

6. c. As nerve involvement ascends, it is very frightening for the patient but 85% to 95% of patients with Guillain-Barré syndrome recover completely with care, although 30% may have a residual weakness. Patients also recover if ventilatory support is provided during respiratory failure. Guillain-Barré syndrome affects only peripheral nerves and does not affect the brain.

7. Which condition is transmitted through wound contamination, causes painful tonic spasms or seizures, and can be prevented by immunization? a. Tetanus b. Botulism c. Neurosyphilis d. Systemic inflammatory response syndrome

7. a. Tetanus is transmitted through wound contamination, causes painful tonic spasms or seizures, and can be prevented with immunization.

8. Which statements describe neurosyphilis (select all that apply)? a. Occurs 10 to 20 years after bacterial infection b. Infection can affect any part of the nervous system c. Descending paralysis with cranial nerve involvement d. Degenerative changes in the spinal cord and brainstem e. Inhibits transmission of acetylcholine at myoneural junction f. Initially manifests with GI symptoms with subsequent absorption of neurotoxin

8. a, b, d. Neurosyphilis occurs 10 to 20 years after syphilis is contracted and is inadequately treated; it affects any part of the nervous system and causes degenerative changes in the spinal cord and brainstem in the later stages. The other options describe botulism.

9. In planning community education for prevention of spinal cord injuries, what group should the nurse target? a. Older men b. Teenage girls c. Elementary school-age children d. Adolescent and young adult men

9. d. Spinal cord injuries are highest in adolescent and young adult men between the ages of 16 and 30 and those who are impulsive or risk takers in daily living. Other risk factors include alcohol and drug abuse as well as participation in sports and occupational exposure to trauma or violence.