MedSurg Chapter 43 Care of Patients with Problems of the Central Nervous System: The Spinal Cord

The nurse is developing a teaching plan for a client with a history of low back pain. Which instructions does the nurse plan to include in teaching the client about preventing low back pain and injury? (Select all that apply.) "Standing for long periods of time will help to prevent low back pain." "Keep weight within 50% of ideal body weight." "Begin a regular exercise program." "When lifting something, the back should be straight and the knees bent." "Do not wear high-heeled shoes." Beginning a regular exercise program will help to promote back strengthening. Keeping the back straight while bending the knees is the proper way to lift objects; this method will help prevent back injury. Wearing high-heeled shoes can increase back strain. The client should avoid standing or sitting for long periods of time because this can cause further strain on the back. Weight should be kept within 10% of ideal body weight.

"Begin a regular exercise program." Correct "When lifting something, the back should be straight and the knees bent." Correct "Do not wear high-heeled shoes." Correct Beginning a regular exercise program will help to promote back strengthening. Keeping the back straight while bending the knees is the proper way to lift objects; this method will help prevent back injury. Wearing high-heeled shoes can increase back strain. The client should avoid standing or sitting for long periods of time because this can cause further strain on the back. Weight should be kept within 10% of ideal body weight.

A client with amyotrophic lateral sclerosis is degenerating rapidly and will soon need respiratory support. What does the nurse plan to review with this client? Advance directives How to use the ventilator Funeral plans Nutritional support

Advance directives. Mechanical ventilation enables the client to breathe and prolongs survival, but it will not alter progression of the disease. For this reason, many clients elect not to be placed on a mechanical ventilator, according to their wishes or advance directives. Ventilator operation and nutrition are not the priority issues to review with this client. Reviewing funeral plans with the client is inappropriate and is not the responsibility of the nurse.

The nurse is caring for a client in the emergency department whose spinal cord was injured at the level of C7 1 hour ago. Which assessment finding requires the most rapid action? Electrocardiographic monitoring shows a sinus bradycardia at a rate of 50 beats/min. The client demonstrates flaccid paralysis below the level of injury. The client's chest moves very little with each respiration. After two fluid boluses, the client's systolic blood pressure remains 80 mm Hg.

Airway and breathing are always of major concern in a spinal cord injury, especially in an injury near C3 to C5, where the spinal nerves control the diaphragm. Symptoms often worsen after injury because of swelling. Bradycardia is consistent with spinal shock and will need to be addressed, but this is not the nurse's first priority. Flaccid paralysis below the level of injury will need to be addressed, but this is not compromising the client's cardiopulmonary status. Systolic blood pressure remaining at 80 mm Hg is consistent with spinal shock and will need to be addressed, but this is not the first priority.

A client returns to the neuromedicine floor after undergoing an anterior cervical diskectomy and fusion (ACDF). What is the nurse's first action? Administer pain medication. Assess airway and breathing. Assist with ambulation. Check the client's ability to void.

Assessment in the immediate postoperative period after an ACDF is maintaining an airway and ensuring that the client has no problem with breathing. Swelling from the surgery can narrow the trachea, causing a partial obstruction. Ambulation, administration of pain medication, and assessing the client's ability to void are important, but are not the highest priority.

In assessing a client with back pain, the nurse uses a paper clip bilaterally on each limb. What is the nurse assessing? Gait Mobility Sensation Strength

Both extremities may be checked for sensation by using a pin or paper clip and a cotton ball for comparison of light and deep touch. The client may feel sensation in both limbs but may experience a stronger sensation on the unaffected side. Gait is assessed by having the client walk. Mobility is assessed by determining the client's level of self-care. Strength is measured by having the client perform bilateral grips.

In addition to frequent re-positioning, the nurse anticipates a consultation request for which special pressure relief device to help prevent pressure ulcers in the client with a spinal cord injury? Chair pad Thromboembolism-deterrent (TED) hose Trapeze Water bottle

Chair pad. In addition to regular turning and re-positioning, special pressure-relief devices such as chair pads may be used in the wheelchair to prevent pressure ulcers in the client with spinal cord injury. TED hose help prevent thrombus, not pressure ulcers. A trapeze helps the client reposition him- or herself; it is not a pressure-relief device. A water bottle is not indicated for the client with spinal cord injury.

In the emergency department (ED), which is the nursing priority in assessing the client with a spinal cord injury? Patent airway Indication of allergies Level of consciousness Loss of sensation

Clients with injuries at or above T6 are at risk for respiratory complications. After assessment of cardiorespiratory status, the level of consciousness must be assessed using the Glasgow Coma Scale. In the ED, determining allergies or loss of sensation is not the first priority in assessing the client with spinal cord injury.

The body temperature of an unconscious patient is never taken by which route? Axillary Mouth Rectal Tympanic

Mouth The body temperature of an unconscious patient is never taken by mouth. Rectal or tympanic (if not contraindicated) temperature measurement is preferred to the less accurate axillary temperature.

The nurse is caring for a client postoperatively after an anterior cervical diskectomy and fusion. Which assessment finding is of greatest concern to the nurse? Neck pain is at a level 7 on a 0-to-10 scale. The client is reporting difficulty swallowing secretions. The client has numbness and tingling bilaterally down the arms. Serosanguineous fluid oozes onto the neck dressing.

Difficulty swallowing may indicate swelling in the neck and the potential for compromise of the client's airway. Experiencing neck pain and numbness and tingling bilaterally down the arms are expected findings after this surgery. Serosanguineous fluid oozing onto the neck dressing is also a normal finding after this surgery.

The nurse is providing instructions to a client with a spinal cord injury about caring for the halo device. The nurse plans to include which instructions? "Begin driving 1 week after discharge." "Avoid using a pillow under the head while sleeping." "Swimming is recommended to keep active." "Keep straws available for drinking fluids."

Keeping straws available makes it easier to drink fluids because the device makes it difficult to bring a cup or a glass to the mouth. Driving should be avoided because vision is impaired with the device. The head should be supported with a small pillow when sleeping to prevent unnecessary pressure and discomfort. Swimming should be avoided to prevent the risk for infection.

A client who has just undergone spinal surgery must be moved. How does the nurse plan to move this client? Getting the client up in a chair Keeping the client in the Trendelenburg position Lifting the client in unison with other health care personnel Log rolling the client

Log rolling the client who has undergone spinal surgery is the best way to keep the spine in alignment. The client who has undergone spinal surgery must remain straight. The Trendelenburg position is not indicated for the client who has undergone spinal surgery, nor should the client be lifted or encouraged to get up in a chair.

The nurse is teaching a client newly diagnosed with multiple sclerosis (MS). Which statement by the client indicates a correct understanding of the pathophysiology of the disease? "I will die early." "I will have gradual deterioration with no healthy times." "Parts of my nervous system have plaques." "This was caused by getting too many x-rays as a child."

MS is characterized by an inflammatory response that results in diffuse random or patchy areas of plaque in the white matter of the central nervous system. The client with MS has no decrease in life expectancy. Frequent times of remission are common in clients with MS. There is no known cause for MS.

The nurse is teaching a client and her husband about sexuality issues after a spinal cord injury. Which comment by the client indicates a correct understanding of the nurse's instruction? "I can no longer become pregnant." "If I become pregnant, I cannot give birth." "I may still be able to get pregnant." "My children will be paralyzed."

Many women with spinal cord injury go on to get pregnant and give birth to healthy children. Spinal cord injury is not a disorder that can be inherited

A client is admitted with a spinal cord injury at the seventh cervical vertebra secondary to a gunshot wound. Which nursing intervention is the priority for this client's care? Auscultating bowel sounds every 2 hours Beginning a bladder retraining program Monitoring nutritional status Positioning the client to maximize ventilation potential

Positioning the client to maximize ventilation potential Airway management is the priority for the client with a spinal cord injury. The client with a cervical spinal cord injury is at high risk for respiratory compromise because the cervical spinal nerves (C3-C5) innervate the phrenic nerve, controlling the diaphragm. Although assessing bowel sounds is important as a sign of neurogenic shock, this is not the priority intervention on admission. Bladder retraining begins as necessary after evaluation of urinary function; a catheter is initially inserted. Monitoring nutritional status is essential only after stabilization from the acute injury.

A family member of a client with a recent spinal cord injury asks the nurse, "Can you please tell me what the real prognosis for recovery is? I don't feel like I'm getting a straight answer." What is the nurse's best response? "Every injury is different, and it is too soon to have any real answers right now." "Only time will tell." "The Health Insurance Portability and Accountability Act requires that I obtain the client's permission first." "Please request a meeting with the health care provider."

Questions concerning prognosis and potential for recovery should be referred to the health care provider. The timing and extent of recovery are different for each client, but it is not the nurse's role to inform the client and family members of the client's prognosis. Telling the family that "only time will tell" is too vague and minimizes the family's concern. The client was informed of Health Insurance Portability and Accountability Act (HIPAA) rights on admission or when consciousness was established, so permission has already been granted by the client.

Which nursing intervention is best for preventing complications of immobility when caring for a client with spinal cord problems? Frequent ambulation Encouraging nutrition Regular turning and re-positioning Special pressure-relief devices

Regular turning and re-positioning are the best way to prevent complications of immobility in clients with spinal cord problems. Frequent ambulation may not be possible for these clients. A registered dietitian may be consulted to encourage nutrition to optimize diet for general health and to reduce osteoporosis. Use of special pressure-relief devices is important, but is not the best way to prevent immobility complications in clients with spinal cord problems.

To prevent the leading cause of death for clients with spinal cord injury, collaboration with which component of the health care team is a nursing priority? Nutritional therapy Occupational therapy Physical therapy Respiratory therapy

Respiratory therapy A client with a cervical spinal cord injury is at risk for breathing problems resulting from an interruption of spinal innervation to the respiratory muscles. In collaboration with the respiratory therapist, the nurse should perform a complete respiratory assessment, including pulse oximetry for arterial oxygen saturation every 8 to 12 hours to prevent respiratory complications such as pneumonia, pulmonary emboli, and atelectasis. Collaboration with nutritional therapy, occupational therapy, and physical therapy does not help prevent the leading cause of death in clients with spinal cord injury.

The nurse is providing medication instructions to a client diagnosed with amyotrophic lateral sclerosis who has been prescribed riluzole (Rilutek). Which statement indicates to the nurse that the client understands the instructions? "Riluzole should be taken with food." "I plan to take riluzole once daily." "I will call the health care provider if my pulse goes below 50." "I will need frequent checks of my liver enzymes."

Riluzole (Rilutek) may cause liver toxicity, and liver enzymes will need to be checked frequently. This drug should be taken twice a day without food and when the stomach is empty. Riluzole may cause tachycardia, not bradycardia.

A client with a spinal cord tumor and a poor prognosis has lost bladder control. The client asks the nurse whether the suggested surgery will be "worth it." What is the nurse's best response? "It should help return bladder control." "Let me call the surgeon so you can ask the rest of our questions." "What do you think?" "What does your family think?"

Surgical decompression may be performed to maintain bladder, bowel, or motor function and to preserve quality of life, even with a poor prognosis. The nurse should ascertain what was explained in the informed consent and then should clarify the information already given by the health care provider. The client must make the decision for surgery, but the nurse should provide additional information to the client, especially if the client asks. The family should not make the decision for surgery, the client should.

A client is being discharged with paraplegia secondary to a motor vehicle crash and expresses concern over the ability to cope in the home setting after the injury. Which is the best resource for the nurse to provide for the client? Hospital library Internet Provider's office National Spinal Cord Injury Association

The National Spinal Cord Injury Association will inform the client of support groups in the area and will assist in answering questions regarding adjustment in the home setting. The hospital library is not typically consumer-oriented; most information available there is targeted to health care professionals. The Internet is not the best resource simply because of the unlimited volume of information available and its questionable quality. The health care provider's office typically does not provide information about spinal cord injury support groups.

A client with a T6 spinal cord injury who is on the rehabilitation unit suddenly develops facial flushing and reports a severe headache. Blood pressure is elevated, and the heart rate is slow. Which action does the nurse take first? Check for fecal impaction. Insert a straight catheter. Help the client sit up. Loosen the client's clothing.

The client is experiencing autonomic dysreflexia, which can produce severe and rapidly occurring hypertension. Getting the client to sit upright is the easiest and quickest action to take and has the most immediate chance of lowering blood pressure to the brain. Checking for fecal impaction, inserting a straight catheter, and loosening the clothing are important, but will not immediately reduce blood pressure.

A client has received preoperative teaching from the nurse for a microdiskectomy. Which statement by the client indicates a correct understanding of the nurse's instruction? "I can go home the day of the procedure." "I can go home 48 hours after the procedure." "I'll have a drain in place after the procedure." "I'll need to wear special stockings after the procedure."

The client who undergoes a microdiskectomy typically can return home the same day. The client who undergoes a traditional open laminectomy typically can return home 48 hours after the procedure, will have a drain in place after the procedure, and will need to wear special stockings after the procedure.

The nurse is caring for a client with a spinal cord injury resulting from a diving accident, who has a halo fixator and an indwelling urinary catheter in place. The nurse notes that the blood pressure is elevated and that the client is reporting a severe headache. The nurse anticipates that the health care provider will prescribe which medication? Dopamine hydrochloride (Inotropin) Nifedipine (Procardia) Methylprednisolone (Solu-Medrol) Ziconotide (Prialt)

This client is experiencing autonomic dysreflexia, which is a neurologic medical emergency that causes severe hypertension and bradycardia; nifedipine (Procardia) is given to treat the elevated blood pressure. Dopamine hydrochloride (Inotropin) is an inotropic agent used to treat severe hypotension. Methylprednisolone (Solu-Medrol) is a glucocorticoid and is not indicated because it may further increase blood pressure. Ziconotide (Prialt) is an N-type calcium channel blocker that is used to treat severe chronic back pain and failed back surgery syndrome and is also used for clients with cancer, AIDS, and unremitting pain from other nervous system disorders.

A client with severe muscle spasticity has been prescribed tizanidine (Zanaflex, Sirdalud). The nurse instructs the client about which adverse effect of tizanidine? Drowsiness Hirsutism Hypertension Tachycardia

Tizanidine (Zanaflex, Sirdalud) is a centrally acting skeletal muscle relaxant, and drowsiness and sedation are common adverse effects. Tizanidine may cause alopecia (not hirsutism), hypotension (not hypertension), and bradycardia (not tachycardia).