Neuro II Practice Questions

A client with a spinal cord injury who has been active in sports and outdoor activities talks almost obsessively about his past activities. In tears, one day he asks the nurse, "Why can't I stop talking about these things? I know those days are gone forever." Which response by the nurse conveys the best understanding of the client's behavior?

"Reviewing your losses is a way to help you work through your grief and loss."

A registered nurse and a nursing assistant are caring for a group of clients. Which client's care may safely be delegated to the nursing assistant?

A client diagnosed with renal calculi who must ambulate four times daily and drink plenty of

Which activities would the client with a T4 spinal cord injury be able to perform independently? Select all that apply.

Eating Breathing Transferring to a wheelchair Writing

The nurse is teaching a 16-year-old client how to self-catheterize following a spinal cord injury. Which statements by the nurse are correct? Select all that apply.

Drink caffeinated drinks sparingly. Self-catheterize according to a schedule. Maintain a regular pattern of fluid intake over the day.

Which approach would be the most therapeutic when working with the parent of a client presenting with quadriplegia as a result of a C-5 spinal cord injury?

Encourage the parent to express feelings and other fears about the injury.

A client, recovering from a spinal cord injury, has a great deal of spasticity. Which medication would the nurse anticipate to relieve spasticity?

Establish an airway with the jaw-thrust maneuver. Immobilize the spine.

The nursing instructor is talking with her clinical group about the central nervous system. What should the instructor tell the students about the function of the spinal cord?

Serves as a conduit for impulses to and from the brain

Which term refers to muscular hypertonicity in a weak muscle, with increased resistance to stretch?

Spasticity

Which are risk factors for spinal cord injury (SCI)? Select all that apply.

Young age Alcohol use Drug abuse

A registered nurse (RN) has been paired with a licensed practical nurse (LPN) for the shift. Whose care should the RN delegate to the LPN?

a 2-year-old child who nearly drowned 2 days earlier

A nurse is assessing pain in a client who has a spinal cord injury. The client states that even a light touch to the legs will illicit severe pain. The client is describing which type of pain?

allodynia

A client with a spinal cord injury has spinal shock. What should the nurse expect the client's bladder function to be at this time?

atonic

A client is being treated for a lumbar spinal injury that occurred 5 days ago and is currently experiencing the symptoms of spinal shock. Characteristic for this condition, the client is unable to move the lower extremities, is being closely monitored for hypotension and bradycardia, and has impaired temperature control. Which would not be an expected outcome of care?

client maintains mechanical ventilation with minimal mucus accumulation

Passive range-of-motion (ROM) exercises for the legs and assisted ROM exercises for the arms are part of the care regimen for a client with a spinal cord injury. Which observation by the nurse would indicate a successful outcome of this treatment?

free, easy movement of the joints

The nurse is admitting a toddler with the diagnosis of near-drowning in a neighbor's heated swimming pool to the emergency department. The nurse should assess the child for which complication?

hypoxia

A patient was admitted to a rehabilitation unit for treatment of a spinal cord injury. The admitting diagnosis is central cord syndrome. During an admissions physical, the nurse expects to find:

loss of motor power and sensation in the upper extremities.

During morning care, a nurse notes that a client who's had a spinal cord injury has experienced a change in level of consciousness and isn't answering questions appropriately. The nurse checks the client's vital signs and measures the client's blood pressure at 180/110 mm Hg and heart rate at 125 beats/minute. The nurse determines that the client may be experiencing dysreflexia. What other assessments should the nurse make? Select all that apply.

most recent bowel movement urine output pain level

During assessment of an adolescent who has sustained a recent thoracic spinal injury, the nurse auscultates the adolescent's abdomen. The nurse explains to the parents that this is necessary because clients with spinal cord injury often develop which problem?

paralytic ileus

A nurse is caring for a client experiencing difficulty swallowing following a spinal cord injury and the placement of a halo traction device. Which nursing interventions are most appropriate for this client? Select all that apply.

place client in an upright position to eat verify that a cough reflex is present verify that a gag reflex is present assist the client to select foods from a mechanical soft diet

A client is being admitted with a spinal cord transection at C7. Which assessments take priority upon the client's arrival? Select all that apply.

respirations temperature blood pressure

Which are characteristics of autonomic dysreflexia?

severe hypertension, slow heart rate, pounding headache, sweating

Urinary tract infection (UTI) is a potential problem after spinal cord injury. To prevent an UTI, the nurse should encourage the client to:

drink at least 2,000 mL of fluid daily

The nurse is taking care of a client with a spinal cord injury. The extent of the client's injury is shown in the accompanying image. Which finding is expected when assessing this client?

dysfunction of bowel and bladder

There is a high risk for ineffective coping in a client with a recent spinal cord injury. Which nursing interventions will assist the client with this process? Select all that apply.

Offer encouragement as the client makes progress. Involve the client actively in self care.

Which stimulus is known to trigger an episode of autonomic dysreflexia in the client who has suffered a spinal cord injury?

Placing a blanket over the client

The nurse is caring for a client experiencing autonomic dysreflexia. Which of the following does the nurse recognize as the source of symptoms?

Sympathetic nervous system

A client jumped out of a window on the second floor of the hospital and sustained a spinal cord injury that resulted in the inability to have upper and lower extremity sensation. What type of documentation by the nurse would be appropriate in this situation?

"Client observed standing on the window ledge; asked client to come down and proceeded to enter the room, and client jumped through the glass."

The nurse is caring for a child who sustained a spinal cord injury in a motor vehicle accident. The child's body temperature fluctuates markedly and the parents question why this is occurring. What is the most accurate response for the nurse to educate the parents?

"The child's sympathetic nervous system was damaged in the accident."

Spinal cord injury is an example of which type of disability?

Acquired

The nurse is caring for a lethargic but arousable preschooler who is a victim of a near-drowning accident. What should the nurse do first?

Administer oxygen.

For a patient with an SCI, why is it beneficial to administer oxygen to maintain a high partial pressure of oxygen (PaO2)?

Because hypoxemia can create or worsen a neurologic deficit of the spinal cord

An adolescent sustains a T3 spinal cord injury. After insertion of an intravenous line, a nasogastric tube, and an indwelling urinary (Foley) catheter, the adolescent is admitted to the intensive care unit. What should the nurse do next when assessment reveals that the adolescent's feet and legs are cool to the touch?

Cover the adolescent's legs with blankets

A nurse is caring for a client with L1-L2 paraplegia who is undergoing rehabilitation. Which goal is appropriate?

Establishing an intermittent catheterization routine every 4 hours

When planning to move a person with a possible spinal cord injury, the nurse should direct the team to move the client using which procedure?

Immobilize the head and neck to prevent further injury.

A nurse, who witnesses an accident involving an adolescent being thrown from a motorcycle, stops to help. The adolescent reports that he is now unable to move his legs. While waiting for the emergency medical service to arrive, what should the nurse do?

Leave the adolescent as he is, staying close by.

Which is the most common cause of spinal cord injury (SCI)?

Motor vehicle crashes

A client with tetraplegia cannot do his own skin care. The nurse is teaching the caregiver about the importance of maintaining skin integrity. Which of the following will the nurse most encourage the caregiver to do?

Maintain a diet for the client that is high in protein, vitamins, and calories.

The nurse is caring for a client immediately after a spinal cord injury. Which assessment finding is essential when caring for a client in spinal shock with injury in the lower thoracic region?

Pulse and blood pressure

As a first step in teaching a woman with a spinal cord injury and quadriplegia about her sexual health, the nurse assesses her understanding of her current sexual functioning. Which statement by the client indicates she understands her current ability?

"I can participate in sexual activity but might not experience orgasm."

An adolescent client is having difficulty coping following the drowning death of a close friend in a boating accident. The client reports to the nurse about having recurring nightmares and intrusive thoughts about the friend's death. Which of the following assessments is most important for the nurse to make?

Availability of social supports

The nurse is working in the rehabilitative setting caring for tetraplegia and paraplegia clients. When instructing family members on the difference between the sites of impairment, which location differentiates the two disorders?

The first thoracic vertebrae

A client with tetraplegia has a spinal cord injury (SCI) at C4. He experiences severe orthostatic hypotension with any elevation of his head. Which of the following interventions will the nurse employ to reduce the hypotension?

Apply anti-embolic stockings prior to elevation of the head.

Which of the following describes a muscle that is limp and without tone?

Flaccid

A client is in a driving accident creating a spinal cord injury. The nurse caring for a client realizes that the client is at risk for which type of shock?

Neurogenic

The nurse is caring for a client with a spinal cord injury. What test reveals the level of spinal cord injury?

Neurologic examination

A client has had corticosteroid therapy initiated within 8 hours of a spinal cord injury. The nurse is aware that this medication is administered for which of the following reasons?

To reduce damage and improve functional recovery

The nurse is caring for a client following a spinal cord injury who has a halo device in place. The client is preparing for discharge. Which statement by the client indicates the need for further instruction?

"I can apply powder under the liner to help with sweating."

A client with a spinal cord injury is to receive Lovenox (enoxaparin) 50 mg subcutaneously twice a day. The medication is supplied in vials containing 80 mg per 0.8 mL. How many mL will constitute the correct dose? Enter the correct number ONLY.

0.5

The nurse is providing information about spinal cord injury (SCI) prevention to a community group of young adults. The nurse mentions that all of the following are predominant risk factors for SCI except?

Being an athlete

A client has been brought to the emergency department after a fall off a roof. The client has no cord function below the point of injury, low blood pressure, and a low heart rate. What would the nurse suspect the client is experiencing?

The client is in spinal shock.

A client who's paralyzed on the left side has been receiving physical therapy and attending teaching sessions about safety. Which behavior indicates that the client accurately understands safety measures related to paralysis?

The client uses a mirror to inspect the skin.

A nurse is preparing a client for magnetic resonance imaging (MRI) to confirm or rule out a spinal cord lesion. During the MRI scan, which action would pose a threat to the client?

The client wears a watch and wedding band.

A patient has an S5 spinal fracture from a fall. What type of assistive device will this patient require?

The patient will be able to ambulate independently.

A nurse is caring for a client with a history of spinal cord injury. Which nursing actions can reduce the risk for autonomic dysreflexia? Select all that apply.

monitor the patency of the indwelling urinary catheter promote a high fiber diet, and the use of a stool softener

A client with a spinal cord injury and subsequent urine retention receives intermittent catheterization every 4 hours. The average catheterized urine volume has been 550 ml. The nurse should plan to

increase the frequency of the catheterizations.

Which actions by the nurse are appropriate when planning care for a client admitted to the intensive care unit after a spinal cord injury? Select all that apply.

gauging level of progress weekly prioritizing areas of client need retiring problems that are resolved

The nurse is offering suggestions regarding reproductive options to a husband and paraplegic wife. Which option is most helpful?

Conception is not impaired; the birth process is determined with the physician.

A client is admitted with a cervical spine injury sustained during a diving accident. When planning this client's care, the nurse should assign highest priority to which nursing diagnosis?

Ineffective breathing pattern

A patient was body surfing in the ocean and sustained a cervical spinal cord fracture. A halo traction device was applied. How does the patient benefit from the application of the halo device?

It allows for stabilization of the cervical spine along with early ambulation.

The most important nursing priority of treatment for a patient with an altered LOC is to:

Maintain a clear airway to ensure adequate ventilation.

A client has a C7 spinal cord injury. Which would be the most important nursing intervention during the acute stage of the injury?

Maintain a patent airway.

The nurse working on a neurological unit is assigned a client with spinal cord injury. Which nursing actions can the nurse delegate to the nursing student on the unit? Select all that apply.

Provide pin care. Administer oral medication to decrease muscle spasticity.

Which of the following are the immediate complications of spinal cord injury?

Respiratory arrest Spinal shock

A client is admitted to the trauma center with a spinal cord transection at T4. Which of the physical limitations does the nurse anticipate when planning care? Select all that apply.

The client will be unable to independently ambulate. The client will have no control of the bladder.

Which are possible long-term complications of spinal cord injury? Select all that apply.

autonomic dysreflexia respiratory infection