Chapter 40
A client who has multiple sclerosis reports increased severe muscle spasticity and tremors. What nursing action is most appropriate to manage this client's concern? A. Request a prescription for an antispasmodic drug such as baclofen. B. Prepare the client for deep brain stimulation surgery. C. Refer the client to a massage therapist to relax the muscles. D. Consult with the occupational therapist for self-care assistance.
A
A nurse assesses a client who is recovering from an open anterior cervical discectomy and fusion. Which complication would alert the nurse to urgently communicate with the primary health care provider? A. Auscultated stridor B. Weak pedal pulses C. Difficulty swallowing D. Inability to shrug shoulders
A
After teaching a client with a high thoracic spinal cord injury, the nurse assesses the client's understanding. Which statement by the client indicates a correct understanding of how to prevent respiratory problems at home? A. "I'll use my incentive spirometer every 2 hours while I'm awake." B. "I'll drink thinned fluids to prevent choking." C. "I'll take cough medicine to prevent excessive coughing." D. "I'll position myself on my right side so I don't aspirate."
A
The nurse is caring for a 60-year-old female client who sustained a thoracic spinal cord injury 10 years ago. For which potential complication will the nurse assess during this client's care? A. Fracture B. Malabsorption C. Delirium D. Anemia
A
A nurse assesses a client who is recovering from an open traditional anterior cervical fusion. Which assessment findings would alert the nursing to a complication from this procedure? (Select all that apply.) A. Difficulty swallowing B. Hoarse voice C. Constipation D. Bradycardia E. Hypertension
A B
The nurse is taking a history on an older adult. Which factors would the nurse assess as potential risks for low back pain? (Select all that apply.) A. Scoliosis B. Spinal stenosis C. Hypocalcemia D. Osteoporosis E. Osteoarthritis
A B C D E
A nurse assesses a client who experienced a spinal cord injury at the T5 level 12 hours ago. Which assessment findings would the nurse correlate with neurogenic shock? (Select all that apply.) A. Heart rate of 34 beats/min B. Blood pressure of 185/65 mm Hg C. Urine output less than 30 mL/hr D. Decreased level of consciousness E. Increased oxygen saturation
A C D
A nurse assesses a client who recently experienced a traumatic spinal cord injury. Which assessment data would the nurse obtain to assess the client's coping strategies? (Select all that apply.) A. Spiritual beliefs B. Level of pain C. Family support D. Level of independence E. Annual income F. Previous coping strategies
A C D F
A nurse promotes the prevention of lower back pain by teaching clients at a community center. Which statement(s) would the nurse include in this education? (Select all that apply.) A. "Participate in an exercise program to strengthen back muscles." B. "Purchase a mattress that allows you to adjust the firmness." C. "Wear flat instead of high-heeled shoes to work each day." D. "Keep your weight within 20% of your ideal body weight." E. "Avoid prolonged standing or sitting, including driving."
A C E
A nurse assesses cerebrospinal fluid leaking onto a client's surgical dressing. What actions would the nurse take? (Select all that apply.) A. Place the client in a flat position. B. Monitor vital signs for hypotension. C. Utilize a bedside commode. D. Assess for abdominal distension. E. Report the leak to the surgeon.
A E
A client is scheduled for a percutaneous endoscopic lumbar discectomy. Which statement by the client indicates a need for further teaching? A. "I should have a lot less pain after surgery." B. "I'll be in the hospital for 2 to 3 days." C. "I should not have any major surgical complications." D. "I could possibly get an infection after surgery."
B
A client who had a complete spinal cord injury at level L5-S1 is admitted with a sacral pressure injury. What other assessment finding will the nurse anticipate for this client? A. Quadriplegia B. Flaccid bowel C. Spastic bladder D. Tetraparesis
B
A nurse assesses a client with multiple sclerosis after administering prescribed fingolimod. For which common side effect would the nurse monitor? A. Peripheral edema B. Facial flushing C. Tachycardia D. Fever
B
A nurse assesses the health history of a client who is prescribed ziconotide for chronic low back pain. Which assessment question would the nurse ask? A. "Are you taking a nonsteroidal anti-inflammatory drug?" B. "Have you been diagnosed with a mental health problem?" C. "Are you able to swallow oral medications?" D. "Do you smoke cigarettes or any illegal drugs?"
B
A nurse teaches a client who is recovering from an open traditional cervical spinal fusion. Which statement would the nurse include in this client's postoperative instructions? A. "Only lift items that are 10 lb (4.5 kg) or less." B. "Wear your neck brace whenever you are out of bed." C. "You must remain in bed for 3 weeks after surgery." D. "You will be prescribed medications to prevent graft rejection."
B
A nurse plans care for a client with a halo fixator. Which interventions would the nurse include in this client's plan of care? (Select all that apply.) A. Remove the vest for client bathing. B. Assess the pin sites for signs of infection. C. Loosen the pins when sleeping. D. Decrease the patient's oral fluid intake. E. Assess the chest and back for skin breakdown.
B E
A client with multiple sclerosis is being discharged from rehabilitation. Which statement would the nurse include in the client's discharge teaching? A. "Be sure that you use a wheelchair when you go out in public." B. "Wear an undergarment brief at all times in case of incontinence." C. "Avoid overexertion, stress, and extreme temperature if possible." D. "Avoid having sexual intercourse to conserve energy."
C
A nurse assesses a client with a spinal cord injury at level T5. The client's blood pressure is 184/95 mm Hg, and the client presents with a flushed face and blurred vision. After raising the head of the bed, what action would the nurse take next? A. Initiate oxygen via a nasal cannula. B. Recheck the client's blood pressure. C. Palpate the bladder for distention. D. Administer a prescribed beta blocker.
C
A nurse cares for a client with a spinal cord injury. With which interprofessional health team member would the nurse collaborate to assist the client with activities of daily living? A. Social worker B. Physical therapist C. Occupational therapist D. Case manager
C
A nurse is caring for a client with paraplegia who is scheduled to participate in a rehabilitation program. The client states, "I don't understand the need for rehabilitation; the paralysis will not go away and it will not get better." How would the nurse respond? A. "If you don't want to participate in the rehabilitation program, I'll let your primary health care provider know." B. "Rehabilitation programs have helped many patients with your injury. You should give it a chance." 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."
C
The nurse is preparing to teach a client recently diagnosed with multiple sclerosis about taking glatiramer acetate. Which statement by the client indicates a need for further teaching? A. "I will rotate injection sites to prevent skin irritation." B. "I need to avoid large crowds and people with infection." C. "I should report any flulike symptoms to my primary health care provider." D. "I will report any signs of infection to my primary health care provider."
C
A nurse assesses a client who is recovering from an open traditional lumbar laminectomy with fusion. Which complications would the nurse report to the primary health care provider? (Select all that apply.) A. Surgical discomfort B. Redness and itching at the incision site C. Incisional bulging D. Clear drainage on the dressing E. Sudden and severe headache
C D E
After teaching a male client with a spinal cord injury at the T4 level, the nurse assesses the his understanding. Which client statements indicate a correct understanding of the teaching related to sexual effects of his injury? (Select all that apply.) A. "I will explore other ways besides intercourse to please my partner." B. "I will not be able to have an erection because of my injury." C. "Ejaculation may not be as predictable as before." D. "I may urinate with ejaculation but this will not cause infection." E. "I should be able to have an erection with stimulation."
C D E
A nurse assesses a client with paraplegia from a spinal cord injury and notes reddened areas over the client's hips and sacrum. What actions would the nurse take? (Select all that apply.) A. Apply a barrier cream to protect the skin from excoriation. B. Perform range-of-motion (ROM) exercises for the hip joint. C. Reposition the client off of the reddened areas. D. Get the client out of bed and into a chair several times a day. E. Apply a pressure-reducing mattress.
C E
A client continues to have persistent low back pain even after using a number of nonpharmacologic pain management strategies. Which prescribed drug would the nurse anticipate that the client might need to manage the pain? A. Oxycontin B. Gabapentin C. Lorazepam D. Tramadol
D
A nurse assesses clients at a community center. Which client is at greatest risk for low back pain? A. A 24-year-old female who is 25 weeks pregnant. B. A 36-year-old male who uses ergonomic techniques. C. A 53-year-old female who uses a walker. D. A 65-year-old female with osteoarthritis.
D
The nurse initiates care for a client with a cervical spinal cord injury who arrives via emergency medical services. What action would the nurse take first? A. Assess level of consciousness. B. Obtain vital signs. C. Administer oxygen therapy. D. Evaluate respiratory status.
D
The nurse is collaborating with the occupational therapist to assist a client with a complete cervical spinal cord injury to transfer from the bed to the wheelchair. What ambulatory aid would be most appropriate for the client to meet this outcome? A. Rolling walker B. Quad cane C. Adjustable crutches D. Sliding board
D
