Lewis- Chapter 61: Peripheral Nerve & Spinal Cord Problems

For a 65 year old woman who has lived with a T1 spinal cord injury for 20 years, which of the following health teaching instructions should the nurse emphasize? a. a mammogram is needed every year b. bladder function tends to improve with age c. heart disease is not common in persons with spinal cord injuries d. as a person ages, the need to change body position is less important

a. a mammogram is needed every year

Urinary function during the acute phase of spinal cord injury is maintained with a. an indwelling catheter b. intermittent catheterization c. insertion of a suprapubic catheter d. use of incontinent pads to protect the skin

A. an indwelling catheterization

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

A. helps the patient understand that working through the grief will be a lifelong process

A nurse is planning care for a client who suffered a spinal cord injury (SCI) involving a T12 fracture 1 week ago. The client has no muscle control of the lower limbs, bowel, or bladder. which of the following should be the nurses' greatest priority? a. prevention of further damage to the spinal cord b. prevention of contractures of the lower extremities c. prevention of skin breakdown of areas that lack sensation d. prevention of postural hypotension when placing the client in a wheelchair

A. prevention of further damage to the spinal cord Rationale: The greatest risk to the client during the acute phase of a SCI is further damage to the spinal cord. Therefore, when planning care, the priority should be the prevention of further damage to the spinal cord by administration of corticosteroids, minimizing movement of the client until spinal stabilization is accomplished through either traction or surgery, and adequate oxygenation of the client to decrease ischemia of the spinal cord.

Goals of rehabilitation for the patient with an injury at the C6 level include (select all that apply) a. stand erect with leg brace b. feed self with hand devices c. drive an electric wheelchair d. assist with transfer activities e. drive adapted van from wheelchair

B, C, D, E

A patient with paraplegia has developed an irritable bladder with reflex emptying. The nurse teaches 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

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

A nurse is caring for a client with a spinal cord injury who reports a severe headache and is sweating profusely. vital signs include BP 220/110, apical heart rate of 54/min. Which of the following acctions should the nurse take first? a. notify the provider b. sit the client upright in bed c. check the client's urinary catheter for blockage d. administer antihypertensive medication

B. sit the client upright in bed Rationale: The greatest risk to the client is experiencing a cerebrovascular accident (stroke) secondary to elevated BP. The first action by the nurse is elevate the head of the bed until the client is in an upright position. this will lower the BP secondary to postural hypotension.

A patient is admitted with a spinal cord injury at the C7 level. During assessment the nurse identifies the presence of spinal shock on finding a. paraplegia with flaccid paralysis b. tetraplegia with total sensory loss c. total hemiplegia with sensory and motor loss d. spastic tetraplegia with loss of pressure sensation

B. tetraplegia with total sensory loss Rationale: 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.

A week following a spinal cord injury at T2, a patient experiences movement in his leg and tells the nurse he is recovering some function. The nurses' best response to the patient is, a. it is really still too soon to know if you will have a return of function b. the 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. im sorry, but the movement is only a reflex and does not indicate normal function

B. the could be a really positive finding. can you show me the movement Rationale: in 1 week following a spinal cord injury, there may be a resolution of the edema of the injury and an end to spinal shock. When spinal shock ends, reflex movement and spasms will occur, which may be mistaken for return of function, but 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.

Two days following a spinal cord injury, a patient asks continually about the extent of impairment that will result from the injury. The best response by the nurse is, 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, an MRI will be done that can reveal the extent of the cord damage d. because long-term rehabilitation can affect the return of tunction, it will be years before we can tell when the complete effect will be

B. the extent of your injury cannot be determined until the secondary injury to the cord is resolved Rationale: 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 rehab.

The healthcare provider has ordered IV dopamine (Intropin) for a patient in the emergency deparement with a spinal cord injury. The nurse determines that the drug is having the desired effect when assessment findings include a. pulse rate of 68 b. respiratory rate of 24 c. BP of 106/82 d. temperature of 96.8

C. BP of 106/82 Rationale: Dopamine is a vasopressor that is used to maintain BP during states of hypotension that occur during neurogenic shock associated with spinal cord injury. Atropine would be used to treat bradycardia. The T reflects some degree of poikilothermism, but this is not treated with medications.

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, the nurses' first action should be to a. initiate 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

C. assess lungs sounds and respiratory rate and depth Rationale: Because pneumonia and atelectasis are potential problems RT ineffective coughing function, the nurse should assess the patient's breath sound and resp function to determine whether secretions are being retained or whether there is progression of resp impairment. Suctioning is not indicated unless lung sounds indicate retained secretions: position changes will help mobilize secretions. Intubation and mechanical ventilation are used if the patient becomes exhausted from labored breathing or if ABGs deteriorate.

An initial incomplete spinal cord injury often results in complete cord damage because of 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. mecheanical transection of the cord by sharp vertebral bone fragments after the initial injury

C. c. infarction and necrosis of the cord caused by edema, hemorrhage, and metabolites Rationale: The primary injury of the spinal cord rarely affects the entire cord, but the patho 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 increase the damage as it extends above and below the injury site.

A patient with a spinal cord injury has spinal shock. The nurse plans care for the patient based on the knowledge that 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

C. c. resolution of spinal shock is manifested by spasticity, hyperreflexia, and reflex emptying of the bladder Rationale: 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 signals the end of spinal shock. Sympathetic function is impaired belwo 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 organ below the injury. Neurogenic shock results from loss of vascular tone caused by the injury and is manifested by hypotension, peripheral vasodilation, and decreased CO. Rehab activities are not contraindicated during spainl shock and should be instituted if the patient's cardiopulmonary status is stable.

A patient with Guillain-Barre syndrome asks whether he is going to die as the paralysis spreads toward his chest. In responding to the patient, the nurse knows that a. patient who require ventilatory support almost always die b. death occurs when nerve damage affects the brain and meninges c. most patient with Guillain-Barre syndrome make a complete recovery d. if death can be prevented, residual paralysis and sensory impairment are usually permanent

C. most patient with Guillain-Barre syndrome make a complete recovery Rationale: As nerve involvement ascends, it is very frightening for the patient, but most patients with GBS recover completely with care. Patients also recover if ventilatory support is provided during respiratory failure. GBS affects only peripheral nerves and does not affect the brain.

Without surgical stabilization, immobilization and traction of the patient with a cervical spinal cord injury most frequently requires the use of a. kinetic beds b. hard cervical collars c. skeletal traction with skull tongs d. sternal-occipital-mandibular immobilizer (SOMI) brace

C. skeletal traction with skull tongs Rationale: Cervical injuries usually require skeletal traction with the use of Crutchfield, Vinke, or other types of skull tongs to immobilize the cervical vertebrae, even if fracture has not occurred. Hard cervical collars are used for minor injuries or for stabilization during emergency transport of the patient. Sandbags are also 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 cervcal traction.

In planning community education for prevention of spinal cord injuries, the nurse targets a. elderly men b. teenage girls c. elementary school-age children d. adolescent and young adult men

D. adolescent and young adult men Rationale: Spinnal cord injuries are highest in young adult men between the ages of 15 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.

One indication for surgical therapy of the patient with a spinal cord injury is when 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

D. evidence of continued compression of the cord is apparent Rationale: 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.

A patient is admitted to the hospital with a CD4 spinal cord injury after a motorcycle collision. The patient's BP is 83/49, and his pulse is 39 beats/min, and he remains orally intubated. The nurse identifies this pathophysiologic response as caused by a. increased vasomotor tone after injury b. a temporary loss of sensation and flaccid paralysis below the level of injury c. loss of parasympathetic nervous system innervation resulting in vasoconstriction d. loss of sympathetic nervous system innervation resulting in peripheral vasodilation

D. loss of sympathetic nervous system innervation resulting in peripheral vasodilation

A nurse is caring for a client who experienced a cervical spine injury 24 hours ago. which of the following types of prescribed medications should the nurse clarify with the provider? a. glucocorticoids b. plasma expanders c. H2 antagonists d. muscle relaxants

D. muscle relaxants Rationale: The client will still be in spinal shock 24 hours following the injury. the client will not experience muscle spasms until after the spinal shock has resolved, making muscle relaxants unnecessary at this time.

Following a T2 spinal cord injury, the patient develops paralytic ileus. While this condition is present, the nurse anticipates that the patient will need a. IV fluids b. tube feedings c. parenteral nutrition d. nasogastric suctioning

D. nasogastric suctioning Rationale: During the first 2 to 3 days after a spinal cord injury, paralytic ileus may occur, and NG 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 had difficulty swallowing and not until peristalsis is returned; PN would be used only if the paralytic ileus was unusally prolonged.

A nurse is caring for a client who has a C4 spinal cord injury. which of the following should the nurse recognize the client as being at the greatest risk for? a. neurogenic shock b. paralytic ileus c. stress ulcer d. respiratory compromise

D. respiratory compromise Rationale: Using the airway, breathing and circulation priority framework, the greatest risk to the client with a SCI at the level of C4 is respiratory compromise secondary to involvement of the phrenic nerve. Maintainance of an airway and provision of ventilator support as needed is the priority intervention.

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

D. will probably be unable to have either psychogenic or reflexogenic erections with no ejaculation or orgasm Rationale: Most patients with a complete lower motor neuron lesion are unable to have either psychogenic or reflexogenic erections, and alterative 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 likey to experience reflexogeic erections with ejaculation. Patients with complete upper motor neuron lesions usually only have reflex sexual function with rare ejaculation.

A patient is admitted to the hospital with Guillain-Barre syndrome. She had a weakness in her feet and ankles that has progressed to weakness with numbness and tingling in both legs. During the acute phase of her illness, the nurse recognizes that 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 damages c. although voluntary motor neurons are damaged by the inflammatory response, the autonomic nervous system is unaffected by the disease d. the most serious complication of this condition is ascending demyelination of the peripheral nerves of the lower brainstem and cranial nerves

a. a. the most important aspect of care is to monitor the patient's respiratory rate and depth and vital capacity Rationale: The most serious complication of GBS is respiratory failure, and it is essential that respiratory rate, depth, and vital capacity are monitored to detect involvement of the 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 parasympathetic NS are involved in the disease and may lead to orthostatic hypotension, hypertension, and may abnormal vagal responses affecting the heart.

A nurse is caring for a client who experienced a cervical spine injury 3 months ago. Which of the following types of bladder management methods should the nurse use for this client? a. condom catheter b. intermittent urinary catheterization c. crede's method d. indwelling urinary catheter

a. condom catheter Rationale: a client who has a cervical spinal cord injury will also have a upper motor neuron injury, which is manifested by a spastic bladder. because the bladder will empty on its own, a condom catheter is an appropriate method and is noninvasive. B & C are for flaccid bladder.

A patient is admitted to the emergency department with a possible cervical spinal cord injury following an automobile crash. During the admission of the patient, the nurse places the highest priority on a. maintaining a patent airway b. assessing the patient for head and other injuries c. maintaining immobilization of the cervical spine d. assessing the patient's motor and sensory function

a. maintaining a patent airway Rationale: 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 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 patients neuro status.

When planning care for the patient with trigeminal neuralgia, the nurse sets the highest priority on the patient outcome of a. relief of pain b. protection of the cornea c. maintenance of nutrition d. maintenance of positive body image

a. relief of pain rationale: The pain of trigeminal neuralgia is excrutiating, and it may occur in clusters that continue for hours. The condition is considered benign with no major effects except the pain.

A patient is admitted to the emergency department with a spinal cord injury at the level of T2. Which of the following findings is of most concern to the nurse? a. SpO2 of 92% b. HR of 42 beats/min c. BP of 88/60 d. loss of motor and sensory function in arms and legs

b. HR of 42 beats/min Rationale: Neurogenic shock associated with cord injuries above the level of T6 greatly decrease the effect of the sympathetic nervous system, and bradycardia and hypotension occur. A heart rate of 42 is not adequate to meet oxygen needs of the body, and while low, the BP is not at a critical point. The O2 sat is ok, and the motor and sensory loss are expected.

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, the nurse recognizes that a. most cord tumors cause autodestruction of the cord as in traumatic injuries b. metastatic tumors are commonly extradural lesions that can be removed completely 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

b. metastatic tumors are commonly extradural lesions that can be removed completely Rationale: Most metastatic tumors are extradural lesions that may be removed successfully with surgery. Most tumors of the spinal cord are slow-growing, do not cause autodestruction, and, with the exception of intradural intramedullary tumors, can be removed with complete functional restoration. 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.

A patient with a C7 spinal cord injury undergoing rehabilitation tells the nurse he must have the flu because he has a bad headache and nausea. The initial action of the nurse is to a. call the physician b. check the patient's temperature c. take the patient's BP d. elevate the HOB to 90 degrees

c. Take the patient's BP