Neuro quiz 1

A patient involved in a high speed motor vehicle accident with sustained multipul injuries and active bleeding is transported to the ER with immobilization devices in place. There is a high probability of cervical spine fracture, the patient has altered mental status and extremities are flaccid. What is the priority nursing assessment

Assess the respiratory pattern and ensure a patent airway

What does the nurse do for a client with a cervical laminectomy that differs from nursing care for a client with a lumbar lami?

Assist with the removal of oral secretions

A nurse is caring for a client with a spinal cord injury during the immediate post injury period. What is the primary focus of nursing care during this immediate phase

Avoid flexion or hyper extension of the spine

A client has paraplegia as a result of a motorcycle accident. What is the reason the nursing care plan should include turning ther client every 1-2 hours

Prevent pressure ulcers

The nurse should expect a client with a spinal cord injury to have some spasticity of the lower extremities, what should the nurse include in the plan of care for the client to prevent the development of lower extremity contractures

Proper positioning

A client with a spinal cord injury has paraplegia. The nurse assesses for which major problem the client ,y's experience in the recovery period

Bladder control

A nurse expects a client with a herniated intervertebral disk to report a sudden increase in pain with which activities

Coughing/sneezing, straining when having a BM

The ER nurse is Assessing and monitoring a patient with a gunshot wound to the middle of the back. Because the patient is at risk for spinal shock what does the nurse monitor for

Decreased BP, bradycardia and flaccid paralysis

A patient with an upper spinal cord injury is at risk for Autonomic Dysreflexia. What is the priority problem for this patient

Decreased cerebral tissue perfusion

A patient with a SCI has paraplegia and paraparesis, the nurse had identified a priority patient problem of inability to ambulate, the nurse assesses the calf area of both legs for swelling, tenderness, redness or possible complaints of pain. This assessment is specific to the increase risk for which condition

Deep vein thrombosis

What does the nurse do to implement bowel and bladder training for a patient with a SCI

Ensure the patient gets sufficient quantity of fluids each day, assist the patient in developing a schedule, teach the patient about high fiber foods, teach the patient to stimulate voiding by stroking the inner thigh, measure bladder residuals with a bladder ultrasound device

The nurse is providing discharge teaching for a patient with a spin , cord injury who will be performing intermittent self catheterization at home, which signs and symptoms will the nurse instruct the patient to report immediately to the primary health care provider

Fever, foul smelling urine

A client has a functional transection of the spinal cord at C7-8 resulting I spinal shock. Which clinical indicators does the nurse expect to identify when assessing the client immediately after the injury

Flaccid paralysis, lack of reflexes below the injury

The nurse and the nursing student are working together to bathe and reposition a patient who is in a halo fixator device. Which action by the nursing student causes the nurse to intervene

Turns the patient by pulling on the top of the halo device

What is a potential adverse outcome of autonomic dysreflexia in a patient with a spinal cord injury

Hypertensive Crisis

The nurse reviews the discharge and hike care instructions with a patient who had back surgery. Which statement by the patient indicates further teaching is needed

I will drive myself to the doctors office next week

The patient is an adolescent who is quadriplegic as a result of a diving accident. The nursing assistant reports that the patient started yelling and spitting at her while she was trying to bathe him. He is angry and hostile, stating nobody is going to do anything else to me I'm going to get out of this place. What is the priority patient problem

Inability to cope with the situation

The nurse is caring for a patient with a recent spinal cord injury, which intervention does the nurse use to target and prevent the potential SCI complication o autonomic dysreflexia

Keep the room warm and control environmental stimuli, monitor stool output and maintain a bowel program, monitor urinary output and check for bladder distention

A nurse finds a victim under the wreckage of a collapsed building, the individual is conscious, supine, breathing satisfactorily and reporting back pain and the inability to move the legs, what action should the nurse take first

Leave the individual lying on the back with instructions not to move and seek additional help

A client with a quadriplegia is placed on a tilt table daily. Each day the angle of the head of the table gradually is increased. what should the nurse identify as it's purpose when the client asks the reason for the tilt table.

Limit loss of calcium from the bones

A patient has just undergone spinal fusion surgery and returned from the operating room 12 hours ago, which task is best to delegate to the nursing assistant

Log roll the patient every 12 hours

The nurse is caring for several patients with SCIs, which task is best to delegate to the nursing assistant

Log roll the patient, maintain proper body alignment and place a bedpan for toileting

After a client is treated for a spinal cord injury the health care provider informs the family that the client is a paraplegic. The family asks what this means, what explanation should the nurse provide

Lower extremities are paralyzed

Which clinical indicator does the nurse expect to identify when assessing a client admitted with a herniated lumbar disc.

Pain radiating to the hip and leg

Assessment of. Patient with lower spinal cord injury confirms that the patient has paralysis of bilateral lower extremities. How does the nurse document the findings

Paraplegia

The nurse is assessing a patient who presented to the ED reporting acute onset of numbness and tingling in the right leg, how does the nurse document this subjective finding

Parathesia

The nurse is assessing a patient with spinal cord injury and recognizes that the patient is experiencing autonomic dysreflexia. What is the nurses priority action

Raise the head of the bed

What should the nurse include in the plan of care for a client who just had a posterior lumbar laminectomy

Reposition the client by log rolling

After suffering a SCI a patient develops autonomic dysreflexia, including a neurogenic bladder. What is the priority patient problem for this condition

Risk for urinary tract infection

Which position is therapeutic and comfortable for a patient with lower back pain

Semi fowlers position with a pillow under the knees to keep them flexed

For which clinical indicator should the nurse assess a client who just had a microdiskectomy for a herniated lumbar disk

Sensory loss in legs

A patient has a long history if chronic back pain and has undergone several back surgeries in the past. At this point, the surgeon is recommending surgical procedure for spine stabilization, which procedure does the nurse anticipate this patient will need

Spinal fusion

A patient has just undergone a laminectomy and returned from surgery at 1300 hours, at 1530 the nurse is performing the change of shift assessment. Which postoperative finding is reported to the surgeon immediately

Swelling or bulging at the operative site, moderate clear drainage on the postoperative dressing

The nurse is giving homecare instructions to the patient that will be discharged home with a halo device, what does the nurse instruct the patient to avoid

Swimming or contact sports, driving

A patient has just undergone a spinal fusion and a laminectomy and has returned from the operating room, which assessments are done in the first 24 hours

Take vital signs every 4 hours and assess for fever and hypotension, perform neuro assessment every 4 hours with attention to movement and sensation, monitor intake and output and assess for urinary retention, observe for clear fluid on or around the dressing and test for glucose

A patient has been talking to his physician about drugs that could potentially be used in the treatment of his chronic low back pain. Which statement by the patient indicates a need for additional teaching

The doctor may prescribe hydromorphone and it may cause drowsiness, I should not drive or drink alcohol when I take it

The nurse is preparing a quad patient for discharge and has taught the patients spouse to assist the patient with a quad cough to prevent respiratory complications. Which observation indicates that the spouse has understood what has been taught

The spouse places her hands below the diaphragm and pushes upward as the patient exhales

What problem is the nurse primarily attempting to prevent when encouraging the client with spinal cord injury to increase oral fluid intake

Urinary tract infection

The nurse is preparing to physically assess a patients subjective report of parathesia in the lower extremities. In order to accomplish this assessment, which assessment technique does the nurse use

Ask the patient to identify sharp and dull sensation by using a paper clip and cotton ball

Patient has had an anterior cervical diskectomy with fusion and has returned from the recovery room. What is the priority assessment

Assess for patency of airway and respiratory effort

A client in the ICU after sustaining a T2 spinal cord injury, which priority intervention should the nurse include in the clients plan of care

Assess for respiratory complications, monitoring and maintaining blood pressure

The nurse is caring for a patient who has been in a long term care facility for several months following a SCI. The patient has had issues with urinalysis retention and subsequent overflow incontinence and a bladder training program was recently initiated. Which are expected outcomes of the training program

Demonstrates a predictable pattern of voiding, is able to empty the bladder completely, does not experience a UTI

The nurse is talking a history on an older adult patient who reports chronic back pain. The nurse seeks to identify factors that are contributing to the pain. Which question is the most useful in eliciting this information

Do you have a history of osteoarthritis

A patient comes to the ER department with back pain, but is alert and oriented and is not having any problems breathing. Her husband is very distraught and when the nurse tries to find out what has happened he yells, just help her now, stop asking ,e these stupid questions, why is it important for the nurse to continue trying to obtain information from the husband

Engaging the husband will help him to calm down and give him and active role

Which statement about spinal shock are accurate

It lasts <48 hours up to a few weeks, there is temporary loss of motor and sensory function, there is temporary loss of reflex and autonomic function

A nurse in a rehab center teaches clients with quadriplegia to use an adaptive wheelchair. Why is it important that the nurse provide this instruction

They usually will never walk

Which neurologic assessment technique does the nurse use to test a patient for sensory function

Touch the skin with a clean paper clip and ask whether it is a dull or sharp sensation