cns

Which statement by the client indicates a need for additional teaching about his or her spinal cord tumor and treatment? a. "I know that because my symptoms occurred so quickly, I am likely to be cured quickly by surgery." b. "I understand that radiation therapy can shrink the tumor but that radiation can cause more problems, too." c. "I am glad you are here to turn me. Laying in one position for a long time makes my pain worse, even if turning is uncomfortable." d. "My family is making some changes at home for me, including moving my bedroom downstairs."

ANS: A Although surgery may relieve symptoms by reducing pressure on the spine and debulking the tumor, some motor and sensory deficits may remain.

Which instruction will 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.

A nurse is caring for a client with an upper motor neuron lesion who wishes to achieve bladder control. Which intervention is most likely to be effective in stimulating initiation of voiding for this client? a. Stroking the inner aspect of the thigh b. Using intermittent catheterization c. Providing digital anal stimulation d. Using the Valsalva maneuver

ANS: A In clients with upper motor neuron problems, such as spinal cord injury, stroking the inner aspect of the thigh, pulling on the pubic hair, pouring warm water over the perineum, and tapping the bladder area are interventions that can initiate voiding.

The nurse monitors for which complication in the client with an incomplete upper motor neuron lesion? a. Contractures b. Hyperreflexia c. Hypotension d. Visual disturbances

ANS: A Individuals with upper motor neuron lesions have muscle spasticity that can lead to contractures once spinal shock has resolved.

The client with a herniated disc is about to be discharged after having a percutaneous laser disc decompression. Which postprocedure instructions will the nurse provide to this client? a. "You should rest in bed for 24 hours before beginning ambulation." b. "You must sleep in a supine position until the bandage is removed." c. "You may feel numbness or tingling in the legs." d. "You will need to wear a brace for 1 week."

ANS: A It is a general practice to advise clients who have undergone this procedure to remain on bedrest for 24 hours and then to begin a progressive ambulation schedule.

Which statement by the male client with a spinal cord injury at T4 (thoracic) indicates the need for further teaching? a. "I will not be able to have an erection because of my injury." b. "Ejaculation may not be predictable as before." c. "I may urinate with ejaculation." d. "I should be able to have an erection with stimulation."

ANS: A Men with injuries above T6 are often 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.

A client complains of a tight, band-like feeling around the trunk and sensations of numbness and tingling in both legs after a motor vehicle crash. Which is the nurse's priority action? a. Immobilizing the client and notifying the physician b. Medicating the client for pain and providing oxygen c. Assessing proprioception while massaging both legs d. Performing ROM exercises on the extremities

ANS: A The client is demonstrating symptoms of spinal cord compression. Prompt treatment is necessary to prevent paralysis and loss of function.

In assessing the client's coping strategies after suffering a traumatic spinal cord injury, it is important for the nurse to obtain which information? (Select all that apply.) a. Spiritual or religious beliefs b. Level of pain c. Family support d. Level of independence e. Annual income f. Prior 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, 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.

A nurse is caring for a client who has undergone a spinal fusion. Which specific postoperative instructions will 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.

Which symptom(s) experienced by a client with a spinal cord injury at the T5 level would alert the nurse to the presence of a complication of this injury? a. Rhinorrhea b. Fever and cough c. Anxiety and restlessness d. Pain radiating from the hip to the knee

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 nurse assesses for which clinical manifestation in the client with MS of the relapsing-remitting 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.

A nurse is preparing a client newly diagnosed with multiple sclerosis for discharge home from a rehabilitation center. The client has been prescribed cyclophosphamide (Cytoxan) and methylprednisolone (Medrol). Which instruction will the nurse include in a teaching plan for the client? a. "Take hot baths." b. "Avoid people with colds." c. "Try to use physical aids such as walkers as little as possible." d. "You may discontinue these medications when your symptoms improve."

ANS: B The client should be taught to avoid individuals with any type of upper respiratory illness because these medications are immunosuppressive.

Which technique will the nurse use to assess proprioceptive function of the lower extremities in a client with a suspected spinal cord injury? a. Asking the client to flex and extend the feet and knees b. With the client's eyes closed, moving the client's toe up or down c. Applying resistance while the client plantar flexes the legs and feet d. Applying pinprick to the lower extremities and comparing bilaterally

ANS: B The proper technique for testing proprioception is to ask the client to close his or her eyes. Move the client's toe up or down and ask him or her to identify the position of the digit.

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. Computerized 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.

In discussing advanced directives, a client with ALS states that he does not want to be placed on a mechanical ventilator. Which is the nurse's best response? a. "You will need to discuss that with your family and physician." 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 may only have to be on the ventilator 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 advanced directives what is to be done when breathing is no longer possible without intervention.

The nurse collaborates most closely with which health care discipline in providing adaptive equipment to assist with activities of daily living in the client with a spinal cord injury? 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, instruct family members or the caregiver about transfer skills, feeding, bathing, dressing, positioning, and skin care.

The nurse monitors for which clinical manifestations in the client with a transection at C4 (cervical)? (Select all that apply.) a. Elbow extension and flexion b. Ipsilateral motor loss with contralateral loss of sensation c. Ability to control the mouth and head d. Intact rapid finger movement e. Loss of sensation in fingers f. Loss of all respiratory function

ANS: C, E C4 and C7 transections are complete injuries, with paralysis and loss of sensation below the injury and preserved sensorimotor control above the injury.

Which nursing diagnoses is a priority for the client with autonomic dysreflexia? a. Impaired Adjustment related to depression b. Self-care Deficit related to spinal cord injury c. Impaired Physical Mobility related to paraplegia d. Impaired Urinary Elimination related to neurogenic bladder

ANS: D For clients with spinal shock, autonomic dysfunction causes an areflexic bladder, leading to urinary retention and neurogenic bladder.

Which technique will the nurse use to assist a client with acute low back pain into the Williams position? a. Place the client in a supine position with the legs elevated. b. Place the client in a high Fowler's position with the legs elevated. c. Place the client in a supine position and have the client flex the knees. d. Place the client in a semi-Fowler's position and have the client flex the knees.

ANS: D To assume the Williams position, the client is placed in a semi-Fowler's position with the knees flexed.

Within 4 hours of a cervical spinal injury, the client can discriminate light touch and position of the arms but cannot perform any motor function. What is the nurse's interpretation of this finding? a. Lateral spinal cord injury b. Central spinal cord injury c. Posterior spinal cord injury d. Anterior spinal cord injury

ANS: D With a spinal cord injury to the anterior portion of the cervical spine, the client may retain some sensory function (touch, vibration, and position are in the posterior portion) but may not have motor function and pain and temperature sensation. Whether the injury is permanent or temporary cannot be ascertained at this time.

The client with relapsing-remitting multiple sclerosis asks why continuous treatment with interferon beta-1a (Avonex) is necessary. Which is the nurse's best response? a. "This medication will help decrease the number and severity of relapses." b. "This medication is given weekly to halt progression of the disease." c. "This medication is given continuously for 1 year to produce a cure." d. "This medication will protect your muscles from spasticity."

ANS: A Interferon beta-1a is a biologic response modifier that is given IM once weekly to decrease the number and severity of relapses.

Which statement made by a client with a spinal cord injury, who is now living at home, indicates correct understanding of preventive strategies for respiratory problems? a. "I use an incentive spirometer every 8 hours." b. "I do not drink much fluids to prevent choking." c. "I take a cough medicine to prevent excessive coughing." d. "I spend most of my time 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 8 hours helps the client expand her or his lungs more fully and prevent atelectasis.

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. Palpating the area over the bladder for distention b. Placing the client in the Trendelenburg position c. Administering oxygen via a nasal cannula d. Performing 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.

A nurse is caring for a client experiencing spinal shock after a spinal cord injury. Which clinical manifestation indicates the resolution of spinal shock? a. The return of reflex activity b. Normalization of the pupillary reflex c. Return of bowel and bladder continence d. Tingling in the extremities below the lesion

ANS: A The resolution of spinal shock is signaled by the return of reflex activity. Note that spinal shock and neurogenic shock are not interchangeable terms and describe different pathologic phenomena.

Which conditions or factors in an adult woman diagnosed with MS are most likely to have contributed to this health problem? a. Dietary factors such as high-fat or high-calorie intake b. Heritability or genetic factors c. Daily intake of aspirin or other nonsteroidal anti-inflammatory drugs (NSAIDs) d. Sedentary lifestyle

ANS: B Having a first-degree relative with MS increases the individual's risk of developing the disease. There is a higher prevalence of certain genes in populations with higher rates of MS.

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

ANS: B Methylprednisolone (Solu-Medrol) should be given within 8 hours of the injury. Clients receiving this therapy usually show improvement in motor and sensory function.

Which statement by a client with lumbosacral pain alerts the nurse to nerve compression rather than muscle injury as the pain source? a. "A heating pad helps the pain." b. "The pain increases when I try to move fast." c. "I'm having difficulty starting and stopping my stream of urine." d. "I am most comfortable lying in my recliner chair with my knees bent."

ANS: C Difficulty starting and stopping the stream of urine or a loss of continence signifies decreased motor nerve function. This condition is not caused by muscle injury.

Which clinical manifestations would serve to alert the nurse to the early onset of MS? a. Hyperresponsive reflexes b. Excessive somnolence c. Nystagmus and ataxia d. Heat intolerance

ANS: C Early signs and symptoms of MS include changes in motor skills, vision, and sensation.

To protect the client with low back pain from injury, which of the following measures does the nurse incorporate into the plan of care? a. Applying moist heat continuously to the affected area b. Using ice packs or ice massage for 1 to 2 hours over the affected area c. Applying heat packs for 20 to 30 minutes at least four times daily d. Advising 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.

A client with multiple sclerosis has been treated for 6 months with mitoxantrone (Novantrone). Which clinical manifestation alerts the nurse to an adverse effect of this medication? a. Periorbital edema b. Black tarry stools c. Crackles in the lungs d. Nausea and vomiting after meals

ANS: C Mitoxantrone (Novantrone) is an antineoplastic agent that can cause cardiotoxicity when used for long periods. Adverse effects are congestive heart failure and dysrhythmias.

Which is the priority teaching focus for the client with an unstable thoracic vertebral fracture that is being treated with immobilization prior to surgery? a. Ensure that the client knows how to apply the immobilizing brace snugly around the trunk. b. Remind him or her to lie immobile on the backboard used to transport injured clients from the field to the hospital. c. Explain that it is important that the trunk remain in alignment. Avoid sitting up, arching the back, or twisting to either side. d. Teach the client to cough and breathe deeply to avoid postoperative complications of atelectasis and pneumonia.

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.

Which intervention is most likely to achieve the expected outcome of preventing deterioration in neurologic status in a client with a vertebral fracture? a. Reorienting the client to time, place, and person, as needed b. Administering the Mini-Mental State Examination c. Immobilizing the affected portion of the spinal column d. Repositioning 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.

A nurse notes reddened areas over the hips and sacrum of a client with paraplegia from a spinal cord injury. Which is the nurse's best action? a. Rubbing the areas with an oil-based lubricant b. Performing hip flexion and extension range-of-motion (ROM) exercises c. Repositioning the client so that the reddened area does not bear weight d. Ensuring that the client sits in a chair at least once each shift

ANS: C The 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 the pressure on these areas through positioning, assistive devices, and skin protection should then be used.

A client with paraplegia is scheduled to participate in a rehabilitation program. The client does not understand the need for rehabilitation and states, "The paralysis will not go away and it will not get better." Which is the nurse's best response? a. "If you would prefer, I will cancel the order." b. "Your doctor ordered the rehabilitation program." c. "Rehabilitation will teach you how to maintain the functional ability you have." d. "When new discoveries are made regarding paraplegia, people in rehabilitation programs will benefit first."

ANS: C There are many purposes for participating in rehabilitation programs, including disability prevention, maintenance of functional ability, and restoration of function.

The client has experienced a lower motor neuron injury and as a result has a flaccid bowel elimination pattern, with infrequent passage of hard, dry stool. The nurse implements which action to assist in relieving this client's constipation? a. Pouring warm water over the perineum b. Tapping the abdomen from left to right c. Daily tap water enemas d. Manual disimpaction

ANS: D For the client with a lower motor neuron injury, the resulting flaccid bowel may require the client to be manually disimpacted. Scheduled toileting and massaging the abdomen from right to left also may be helpful.

The early manifestations of amyotrophic lateral sclerosis (ALS) and 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, there is progressive muscle atrophy until a flaccid quadriplegia develops. Eventually, there is involvement of the respiratory muscles, which leads to respiratory compromise.

The nurse correlates which pathophysiologic process to the client with a diagnosis of multiple sclerosis (MS)? a. Poor cellular repair mechanisms support the proliferation of dysfunctional neurons. b. The autoimmune response causes damage to unmyelinated nerve fibers. c. Degeneration of axonal bodies interferes with signal transmission. d. Damage to the myelin sheath causes an inflammatory response.

ANS: D In MS, the myelin sheath is damaged, leading to an inflammatory response.

Which clinical manifestation alerts the nurse to the possibility of sciatic nerve impairment in a client with back pain? a. The client has pain that radiates down the arm. b. The client has a loss of handgrip strength. c. The client has a shuffling gait. d. The client walks with a limp.

ANS: D In clients with low back pain, walking with a limp is usually indicative of sciatic nerve impairment.

Which postoperative complaint voiced by a client who had a diskectomy 6 hours ago requires priority action? a. Fatigue b. Thirst c. Restlessness d. Inability to void

ANS: D Inability to void may indicate damage to the sacral spinal nerves.

The client is scheduled to have central nervous system magnetic resonance imaging (MRI). Which nursing intervention is most appropriate in preparation for this procedure? a. Ensuring that the person does not eat for 6 to 8 hours before the procedure b. Discontinuing all neuroactive medications and foods 3 to 4 hours before the procedure c. Making sure that the client has an identifier that cannot be removed d. Replacing the 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.

A client presents with an acute exacerbation of multiple sclerosis. Which drug will the nurse be prepared to administer? a. Baclofen (Lioresal) b. Interferon beta-1b (Betaseron) c. Dantrolene sodium (Dantrium) d. Methylprednisolone (Medrol)

ANS: D Methylprednisolone is the drug of choice for acute exacerbations of the disease.

Which risk factor does the nurse recognize that may predispose an individual to back pain? a. Inherited factors b. Poor posture c. Degenerative joint disease d. Obesity

ANS: D Obesity places increased stress on back muscles and this strain can contribute to the severity of back pain.

In providing discharge teaching to a client after a lumbar laminectomy, the nurse instructs the client to return to the hospital for which potential complication? 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.

A client has arrived by ambulance at the emergency department after a cervical spinal cord injury. Which assessment is a priority for the nurse to perform at this time? a. Mental status 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. Priority nursing diagnoses include Ineffective Airway Clearance, Ineffective Breathing Pattern, and Impaired Gas Exchange.

A nurse is assessing deep tendon reflexes in a client who sustained a spinal cord injury 5 days ago. The nurse can elicit a mild response to a tap on the patella. Which is the nurse's interpretation of this finding? a. There is a gradual response of all the nerves and muscles. b. It is too early to tell how extensive the injury is at this time. c. The injury has resulted in only temporary spinal cord dysfunction. d. The spinal shock phase of the injury is over.

ANS: D The patellar reflex is an ipsilateral response of lower motor neurons. It can remain intact even when the spinal cord is completely severed because this reflex does not require input from upper motor neurons or interneurons. Return of reflexes is a sign of spinal shock resolution. Note that spinal shock is not neurogenic shock.