Complex - Chapter 60 Spinal Cord and Peripheral Nerve Problems Complex Fall 2021

The nurse performs discharge teaching for a 34-yr-old male patient with a thoracic spinal cord injury (T2) from a construction accident. Which statement indicates the patient understands teaching about autonomic dysreflexia? "I will perform self-catheterization at least 6 times per day." "A reflex erection may cause an unsafe drop in blood pressure." "If I develop a severe headache, I will lie down for 15 to 20 minutes." "I can avoid this problem by taking medications to prevent leg spasms."

"I will perform self-catheterization at least 6 times per day." Rationale: Autonomic dysreflexia usually is caused by a distended bladder. Performing self-catheterization 5 or 6 times a day prevents bladder distention. Signs and symptoms of autonomic dysreflexia include a severe headache, hypertension, bradycardia, flushing, piloerection (goosebumps), and nasal congestion. Patients should raise the head of the bed to 45 to 90 degrees. This action helps to relieve hypertension (systolic pressure up to 300 mm Hg) that occurs with autonomic dysreflexia.

In which order does Guillain-Barré syndrome (GBS) develop and resolve? 1.The muscle innervated by the damaged nerve undergoes denervation and atrophy. 2.The myelin layer of the affected nerves is lost. 3.The nerve undergoes slow remyelination. 4.The transmission of nerve impulses is slowed or stopped. 5.The neurologic function returns in a proximal-to-distal pattern.

3.The nerve undergoes slow remyelination. 4.The transmission of nerve impulses is slowed or stopped. 1.The muscle innervated by the damaged nerve undergoes denervation and atrophy. Guillain-Barré syndrome occurs due to an immune reaction directed at the nerves. The nerves undergo segmental demyelination, which means there is loss of myelin of the affected nerves. This leads to slowing or stopping of transmission of nerve impulses. There is denervation and atrophy of the muscle innervated by the damaged nerve. After this, the recovery phase starts. The nerve undergoes slow remyelination, and the neurologic function returns in a proximal-to-distal pattern.

A patient with neurogenic shock after a spinal cord injury is to receive lactated Ringer's solution 400 mL over 20 minutes. When setting the IV pump to deliver the IV fluid, the nurse should set the rate at how many milliliters per hour?

ANS: 1200 To administer 400 mL in 20 minutes, the nurse will need to set the pump to run at 1200 mL/hr.

A patient hospitalized with a new diagnosis of Guillain-Barré syndrome has numbness and weakness of both feet. Which intervention should the nurse anticipate? a. Infusion of immunoglobulin b. Administration of corticosteroids c. Intubation and mechanical ventilation d. Insertion of a nasogastric (NG) feeding tube

ANS: A Because Guillain-Barré syndrome is in the earliest stages (as evidenced by the symptoms), use of high-dose immunoglobulin is appropriate to reduce the extent and length of symptoms. Mechanical ventilation and enteral nutrition may be used later in the progression of the syndrome but are not needed now. Corticosteroids are not helpful in reducing the duration or symptoms of the syndrome.

Which action should the nurse include in the plan of care for a patient who has cauda equina syndrome related to spinal cord injury? a. Catheterize patient every 3 to 4 hours. b. Assist patient to ambulate 4 times daily. c. Administer medications to reduce bladder spasm. d. Stabilize the neck when repositioning the patient.

ANS: A Patients with cauda equina syndrome have areflexic bladder, and intermittent catheterization will be used for emptying the bladder. Because the bladder is flaccid, antispasmodic medications will not be used. The legs are flaccid with cauda equina syndrome, and the patient will be unable to ambulate. The head and neck will not need to be stabilized after a cauda equina injury, which affects the lumbar and sacral nerve roots.

Which collaborative and nursing actions should the nurse include in the plan of care for a patient who experienced a T2 spinal cord transection 24 hours ago? (Select all that apply.) a. Urinary catheter care b. Nasogastric (NG) tube feeding c. Continuous cardiac monitoring d. Administration of H2 receptor blockers e. Maintenance of a warm room temperature

ANS: A, C, D, E The patient is at risk for bradycardia and poikilothermia caused by sympathetic nervous system dysfunction and should have continuous cardiac monitoring and maintenance of a relatively warm room temperature. To avoid bladder distention, a urinary retention catheter is used during this acute phase. Stress ulcers are a common complication but can be avoided through the use of the H2 receptor blockers. Gastrointestinal motility is decreased initially, and NG suctioning is indicated

Which action should the nurse recognize has the highest priority for a patient who was admitted 16 hours earlier with a C5 spinal cord injury? a. Cardiac monitoring for bradycardia b. Assessment of respiratory rate and effort c. Administration of low-molecular-weight heparin d. Application of pneumatic compression devices to legs

ANS: B Edema around the area of injury may lead to damage above the C4 level, so the highest priority is assessment of the patient's respiratory function. The other actions also are appropriate for preventing deterioration or complications but are not as important as assessment of respiratory effort.

A patient with paraplegia resulting from a T9 spinal cord injury has a neurogenic reflexic bladder. Which action should the nurse include in the plan of care? a. Teach the patient to use the Credé method. b. Instruct the patient how to self-catheterize. c. Catheterize for residual urine after voiding. d. Assist the patient to the toilet every 2 hours.

ANS: B Because the patient's bladder is spastic and will empty in response to overstretching of the bladder wall, the most appropriate method is to avoid incontinence by emptying the bladder at regular intervals through intermittent catheterization. Assisting the patient to the toilet will not be helpful because the bladder will not empty. The Credé method is more appropriate for a bladder that is flaccid, such as occurs with areflexic neurogenic bladder. Catheterization after voiding will not resolve the patient's incontinence.

The nurse is admitting a patient who has a neck fracture at the C6 level to the intensive care unit. Which finding on the nursing assessment is congruent with neurogenic shock? a. Involuntary and spastic movement b. Hypotension and warm extremities c. Hyperactive reflexes below the injury d. Lack of sensation or movement below the injury

ANS: B Neurogenic shock is characterized by hypotension, bradycardia, and vasodilation leading to warm skin temperature. Spasticity and hyperactive reflexes do not occur at this stage of spinal cord injury. Lack of movement and sensation indicate spinal cord injury but not neurogenic shock.

A 20-yr-old patient who sustained a T2 spinal cord injury 10 days ago tells the nurse, "I want to be transferred to a hospital where the nurses know what they are doing." Which action should the nurse appropriately take? a. Perform care without responding to the comments. b. Ask the patient to provide input for the plan of care. c. Tell the patient abusive language will not be tolerated. d. Reassure the patient about the competence of the nursing staff.

ANS: B The patient is demonstrating behaviors consistent with the anger phase of the grief process. The nurse should allow expression of anger and seek the patient's input into care. Expression of anger is appropriate at this stage and should be accepted by the nurse. Reassurance about the competency of the staff will not be helpful in addressing the patient's concerns. Ignoring the patient's comments will increase the patient's anger and sense of helplessness.

What should the nurse include in a rehabilitation plan as an appropriate goal for a 30-yr-old patient with a C6 spinal cord injury? a. Drive a car with powered hand controls. b. Propel a manual wheelchair on a flat surface. c. Turn and reposition independently when in bed. d. Transfer independently to and from a wheelchair.

ANS: B The patient with a C6 injury will be able to use the hands to push a wheelchair on flat, smooth surfaces. Because flexion of the thumb and fingers is minimal, the patient will not be able to grasp a wheelchair during transfer, drive a car with powered hand controls, or turn independently in bed.

What should the nurse explain to the patient who has a T2 spinal cord transection injury? a. Total loss of respiratory function may occur. b. Function of both arms should be maintained. c. Use of the patient's shoulders will be limited. d. Tachycardia is common with this type of injury.

ANS: B The patient with a T2 injury can expect to retain full motor and sensory function of the arms. Use of only the shoulders is associated with cervical spine injury. Loss of respiratory function occurs with cervical spine injuries. Bradycardia is associated with injuries above the T6 level.

A patient with a T4 spinal cord injury asks the nurse if he will be able to be sexually active. Which information should the nurse include in an initial response? a. Reflex erections frequently occur, but orgasm may not be possible. b. Sildenafil (Viagra) is used by many patients with spinal cord injury. c. Multiple options are available to maintain sexuality after spinal cord injury. d. Penile injection, prostheses, or vacuum suction devices are possible options.

ANS: C Although sexuality will be changed by the patient's spinal cord injury, there are options for expression of sexuality and for fertility. The other information also is correct, but the choices will depend on the degrees of injury and the patient's individual feelings about sexuality.

A patient who had a C7 spinal cord injury 1 week ago has a weak cough effort and crackles. What initial intervention should the nurse perform? a. Suction the patient's nasopharynx. b. Notify the patient's health care provider. c. Push upward on the epigastric area as the patient coughs. d. Encourage incentive spirometry every 2 hours during the day.

ANS: C Because the cough effort is poor, the initial action should be to use assisted coughing techniques to improve the patient's ability to mobilize secretions. The use of the spirometer may improve respiratory status, but the patient's ability to take deep breaths is limited by the loss of intercostal muscle function. Suctioning may be needed if the patient is unable to expel secretions by coughing but should not be the nurse's first action. The health care provider should be notified if airway clearance interventions are not effective or additional collaborative interventions are needed.

Which assessment data for a patient who has Guillain-Barré syndrome will require the nurse's most immediate action? a. The patient's sacral area skin is reddened. b. The patient reports severe pain in the feet. c. The patient is continuously drooling saliva. d. The patient's blood pressure (BP) is 150/82 mm Hg.

ANS: C Drooling indicates decreased ability to swallow, which places the patient at risk for aspiration and requires rapid nursing and collaborative actions such as suctioning and possible endotracheal intubation. The foot pain should be treated with appropriate analgesics, the BP requires ongoing monitoring, and the skin integrity requires intervention, but these actions are not as urgently needed as maintenance of respiratory function.

To prevent autonomic dysreflexia, which nursing action should the home health nurse include in the plan of care for a patient who has paraplegia at the T4 level? a. Support selection of a high-protein diet. b. Discuss options for sexuality and fertility. c. Assist to plan a prescribed bowel program. d. Use quad coughing to strengthen cough efforts.

ANS: C Fecal impaction is a common stimulus for autonomic hyperreflexia. Dietary protein, coughing, and discussing sexuality and fertility should be included in the plan of care but will not reduce the risk for autonomic hyperreflexia.

A patient with a history of T3 spinal cord injury is admitted with dermal ulcers. The patient tells the nurse, "I have a pounding headache and I feel sick to my stomach." Which action should the nurse take first? a. Check for a fecal impaction. b. Give the prescribed antiemetic. c. Assess the blood pressure (BP). d. Notify the health care provider.

ANS: C The BP should be assessed immediately when a patient with an injury at the T6 level or higher reports a headache. This will help determine if autonomic hyperreflexia is occurring. Notification of the patient's health care provider is appropriate after the BP is obtained. Administration of an antiemetic is indicated if autonomic dysreflexia is ruled out as the cause of the nausea. After checking the BP, the nurse may assess for a fecal impaction using lidocaine jelly to prevent further increased BP.

A 38-yr-old patient who has had a spinal cord injury returned home following a stay in a rehabilitation facility. The home care nurse notes the spouse is performing many of the activities that the patient had been managing unassisted during rehabilitation. What should the nurse identify as the most appropriate action at this phase of rehabilitation? a. Remind the patient about the importance of independence in daily activities. b. Tell the spouse to stop helping because the patient can perform activities independently. c. Develop a plan to increase the patient's independence in consultation with the patient and the spouse. d. Recognize that it is important for the spouse to be involved in the patient's care and encourage participation.

ANS: C The best action by the nurse will be to involve all parties in developing an optimal plan of care. Because family members who will be assisting with the patient's ongoing care need to believe their input is important, telling the spouse that the patient can perform activities independently is not the best choice. Reminding the patient about the importance of independence may not change the behaviors of the spouse. Supporting the activities of the spouse will lead to ongoing dependency by the patient.

A patient is hospitalized with new onset of Guillain-Barré syndrome. What should the nurse recognize as the most essential assessment to complete? a. Determining level of consciousness b. Checking strength of the extremities c. Observing respiratory rate and effort d. Monitoring the cardiac rate and rhythm

ANS: C The most serious complication of Guillain-Barré syndrome is respiratory failure, and the nurse should monitor respiratory function continuously. The other assessments will be included in nursing care, but they are not as important as respiratory assessment.

A patient has an incomplete left spinal cord lesion at the level of T7, resulting in Brown-Séquard syndrome. Which action should the nurse include in the plan of care? a. Assessment of the patient for right arm weakness b. Assessment of the patient for increased right leg pain c. Positioning the patient's left leg when turning the patient d. Teaching the patient to verify the position of the right leg

ANS: C The patient with Brown-Séquard syndrome has loss of motor function on the ipsilateral side and will require the nurse to move the left leg. Pain sensation will be lost in the patient's right leg. Arm weakness will not be a problem for a patient with a T7 injury. The patient will retain position sense for the right leg.

Which nursing action for a patient with Guillain-Barré syndrome should the nurse identify as appropriate to delegate to experienced unlicensed assistive personnel (UAP)? a. Instilling artificial tears b. Assessing for bladder distention c. Administering bolus enteral nutrition d. Performing passive range of motion to extremities

ANS: D Assisting a patient with movement is included in UAP education and scope of practice. Administration of enteral nutrition, administration of ordered medications, and assessment are skills requiring more education and expanded scope of practice, and the RN should perform these skills.

In which order should the nurse perform the following actions for a patient admitted to the emergency department with possible C5 spinal cord trauma? (Put a comma and a space between each answer choice [A, B, C, D, E].) a. Infuse normal saline at 150 mL/hr. b. Monitor cardiac rhythm and blood pressure. c. Administer O2 using a non-rebreather mask. d. Immobilize the patient's head, neck, and spine. e. Transfer the patient to radiology for spinal computed tomography (CT).

ANS: D, C, B, A, E The first action should be to prevent further injury by stabilizing the patient's spinal cord if the patient does not have penetrating trauma. Maintenance of oxygenation by administration of 100% O2 is the second priority. Because neurogenic shock is a possible complication, monitoring of heart rhythm and BP are indicated followed by infusing normal saline for volume replacement. A CT scan to determine the extent and level of injury is needed once initial assessment and stabilization are accomplished.

The arterial blood gas (ABG) report of a patient with a spinal cord injury indicates respiratory distress. The nurse anticipates that which interventions will be included in the patient's treatment plan? Select all that apply. Administer oxygen. Administer steroids. Administer antibiotic drugs. Perform tracheal suctioning if crackles are present. Perform assisted coughing.

Administer oxygen. Perform tracheal suctioning if crackles are present. Perform assisted coughing. To maintain adequate ventilation, the nurse should administer oxygen until ABGs stabilize. Assisted (augmented) coughing simulates the action of the ineffective abdominal muscles during the expiratory phase of a cough, therefore facilitating the removal of secretions. Tracheal suctioning is performed if crackles or rhonchi are present, as indicated by mucus stuck to the airways. Presence of an infection cannot be revealed by an ABG report; therefore it is not appropriate to administer antibiotics. ABG does not reveal any presence of inflammatory process; therefore it is inappropriate to administer steroids to this patient.

A patient has been admitted with a C5 level spinal cord injury and experiences severe hypotension. Which pharmacologic therapies does the nurse expect to be prescribed for this patient? Select all that apply. Nitrates Diuretics Beta blockers Anticoagulants IV fluids

Anticoagulants IV fluids The spinal cord injury at the C5 level causes loss of sympathetic nervous system tone in peripheral vessels. This results in chronic low BP with potential postural hypotension. Lack of muscle tone to aid venous return can result in sluggish blood flow, thus predisposing the patient to deep vein thrombosis. To treat hypotension, a vasopressor agent such as dopamine or norepinephrine should be administered. Fluid replacement also helps in maintaining optimal BP. Nitrates are potent vasodilators and would worsen the hypotension if administered. Diuretics increase fluid loss from the body and may worsen hypotension. Beta blockers decrease the heart rate and cardiac output, which lower BP and make the heart beat more slowly and with less force; this is inappropriate to treat hypotension.

The nurse assists with the prehospital care of a patient who experienced a 15-foot fall. Which action by the nurse will limit the damage if a spinal cord injury (SCI) has occurred? Initiating an IV access peripherally Maintaining an open airway using the head tilt method Determining whether the patient is oriented to person, place, and time Applying a rigid cervical collar and using a backboard to transport the patient

Applying a rigid cervical collar and using a backboard to transport the patient Application of a rigid neck collar and use of a backboard will immobilize and stabilize the cervical spine to limit immediate injury to the spinal cord. Initiation of IV access is important but is not directly associated with limiting the SCI. Patient orientation will not stabilize a SCI. The airway must be maintained with the jaw thrust technique if SCI is suspected.

A patient diagnosed with Guillain-Barré syndrome who has a weak gag reflex would be at risk for which complication? Severe vomiting Difficulty breathing Impaired taste sensations Aspiration of food into the airways

Aspiration of food into the airways The gag reflex is a protective mechanism of the body to prevent anything from entering the respiratory tract via the throat. Therefore a weak gag reflex may cause aspiration, and the nurse should be watchful for this condition. In addition to testing for the gag reflex, the nurse should note drooling and other difficulties with secretions that may indicate an inadequate gag reflex. Manually eliciting a strong gag reflex may cause vomiting. The nurse should intervene if the patient has severe vomiting, difficulty breathing, or impaired taste sensation; however, these symptoms are not caused by a weak gag reflex.

A 22-yr-old woman with paraplegia after a spinal cord injury tells the home care nurse she has bowel incontinence 2 or 3 times each day. Which action should the nurse perform first? Insert a rectal stimulant suppository. Have the patient to gradually increase intake of high-fiber foods. Assess bowel movements for frequency, consistency, and volume. Teach the patient to avoid all caffeinated and carbonated beverages.

Assess bowel movements for frequency, consistency, and volume. Rationale: The nurse should establish baseline bowel function and explore the patient's current knowledge of an appropriate bowel management program after spinal cord injury. To prevent constipation, caffeine intake should be limited but need not be eliminated. After stabilization, creation of a bowel program including a rectal stimulant, digital stimulation, or manual evacuation at the same time each day will regulate bowel elimination. Instruction on high-fiber foods is indicated if the patient has a knowledge deficit.

Which assessment finding would the nurse interpret as a manifestation of neurogenic shock in a patient with acute spinal cord injury? Bradycardia Hypertension Neurogenic spasticity Bounding pedal pulses

Bradycardia Rationale: Neurogenic shock is caused by the loss of vasomotor tone after injury and is characterized by bradycardia and hypotension. Loss of sympathetic innervation causes peripheral vasodilation, venous pooling, and decreased cardiac output. Thus hypertension, neurogenic spasticity, and bounding pedal pulses are not seen in neurogenic shock.

The nurse is providing care to a patient with a spinal cord injury as the result of a motor vehicle accident. The nurse notes that the patient feels no pain in the leg on the side opposite the injury. Which spinal cord syndrome does the nurse suspect? Central cord syndrome Anterior cord syndrome Cauda equina syndrome Brown-Séquard syndrome

Brown-Séquard syndrome Brown-Séquard syndrome results from damage to one half of the spinal cord. A contralateral (opposite side of the injury) loss of pain and temperature sensation below the level of the injury is a manifestation of the syndrome. Central cord syndrome is caused by damage to the central spinal cord. Motor weakness and sensory loss are the common manifestations of this syndrome. Anterior cord syndrome is caused by damage to the anterior spinal artery and often results in motor paralysis and loss of temperature and pain sensation below the level of the injury. Cauda Equina syndrome results from damage to the lowest portion of the spinal cord. Flaccid paralysis of the lower limbs and areflexic bladder and bowel are the common manifestations.

The nurse is caring for a patient admitted to the hospital after a motor vehicle accident. The patient is unable to breathe independently and has been intubated and placed on a ventilator. On the basis of these data, which level of spinal cord injury does the nurse suspect? C1-C3 C4 C5 C6

C1-C3 An injury to C1-C3 is often fatal. The patient retains movement in the neck and above but has a loss of innervation to the diaphragm and an absence of independent respiratory function. A patient with a C4 injury retains sensation and movement in the neck and above. The patient may be able to breathe without a ventilator. A patient who experiences a C5 injury retains full neck movement and partial shoulder, back, and bicep movement. The patient has a gross ability to move the elbow but is unable to roll over or use the hands. The patient also often has a decreased respiratory reserve. A patient with a C6 injury can move the shoulders and upper back, is able to perform abduction and rotation at the shoulder, and has full biceps to elbow flexion and wrist extension, a weak thumb grasp, and decreased respiratory reserve.

A patient with a T3 level spinal cord injury has been discharged from the hospital with an indwelling catheter. Which instructions does the nurse give to the patient regarding catheter care? Select all that apply. Cleanse the catheter regularly. Always keep the urine bag above the waist. Limit water intake to less than a liter a day. Check for the presence of any folds or kinks in the catheter tube. Observe the urine for cloudiness or change in odor.

Cleanse the catheter regularly. Check for the presence of any folds or kinks in the catheter tube. Observe the urine for cloudiness or change in odor. Indwelling catheters should be cleaned regularly, and the method of cleaning should be taught properly by the nurse to the patient to avoid any infections. The patency of the catheter tube should always be checked to prevent any accumulation of urine in the bladder. Long-term use of an indwelling catheter may be associated with urinary tract infection. Signs and symptoms of these conditions should be explained to the patient. The urine bag should always be placed below the level of the bladder to ensure proper drainage. Patients with indwelling catheters need to have an adequate fluid intake (at least 3 to 4 L/day).

Which condition would the nurse expect to find during the physical examination of a patient with cauda equina syndrome (CES)? Diminished temperature sensation Loss of fine and gross motor function Difficulty maintaining proprioception Complete sensation loss between the legs

Complete sensation loss between the legs CES is diagnosed when a person experiences damage to the cauda equina, which are the lumbar and sacral nerve roots. The clinical manifestations include asymmetric distal weakness with a complete loss of sensation between the legs, buttocks, inner thighs, and backs of the legs (the saddle area). Diminished temperature sensation occurs with anterior cord syndrome. Loss of fine and gross motor function occurs with Brown-Séquard syndrome. Difficulty maintaining proprioception can occur with a stroke to the upper spinal cord, which is an incomplete spinal cord injury.

The nurse is providing care to a patient with a spinal cord injury who has areflexic bladder. Which syndrome does the nurse anticipate? Central cord syndrome Anterior cord syndrome Brown-Séquard syndrome Conus medullaris syndrome

Conus medullaris syndrome Conus medullaris syndrome results from damage to the conus, the lowest part of the spinal cord; it causes flaccid paralysis of the lower limbs and areflexic bladder and bowels. Central cord syndrome is caused by damage to the central spinal cord; it results in motor weakness and sensory loss in the upper and lower extremities. Anterior cord syndrome is damage to the anterior spinal artery, which results in compromised blood flow to the anterior spinal cord. Brown-Séquard syndrome is caused by damage to one half of the spinal cord; it results in ipsilateral and contralateral paralysis.

During rehabilitation, a patient with spinal cord injury begins to ambulate with long leg braces. Which level of injury does the nurse associate with this degree of recovery? a. L1-2 b. T6-7 c. T1-2 d. C7-8

Correct answer: a During rehabilitation, the patient with SCI at L1-2 can maintain good sitting balance and full use of a wheelchair. The patient ambulates with long leg braces. Patients with higher level injury are unable to attain this degree of ambulation.

During rehabilitation, a patient with spinal cord injury begins to ambulate with long leg braces. Which level of injury does the nurse associate with this degree of recovery? a. L1-2 b. T6-7 c. T1-2 d. C7-8

Correct answer: a During rehabilitation, the patient with SCI at L1-2 can maintain good sitting balance and full use of a wheelchair. The patient ambulates with long leg braces. Patients with higher level injury are unable to attain this degree of ambulation.

A patient with a T4 spinal cord injury has neurogenic shock due to sympathetic nervous system dysfunction. What would the nurse recognize as characteristic of this condition? a. Tachycardia b. Hypotension c. Increased cardiac output d. Peripheral vasoconstriction

Correct answer: b Rationale: Neurogenic shock results from loss of vasomotor tone caused by injury and is characterized by hypotension and bradycardia. Loss of sympathetic nervous system innervation causes peripheral vasodilation, venous pooling, and a decrease in cardiac output. These effects are usually associated with a cervical or high thoracic injury (T6 or higher).

A patient with a T4 spinal cord injury has neurogenic shock due to sympathetic nervous system dysfunction. What would the nurse recognize as characteristic of this condition? a. Tachycardia b. Hypotension c. Increased cardiac output d. Peripheral vasoconstriction

Correct answer: b Rationale: Neurogenic shock results from loss of vasomotor tone caused by injury and is characterized by hypotension and bradycardia. Loss of sympathetic nervous system innervation causes peripheral vasodilation, venous pooling, and a decrease in cardiac output. These effects are usually associated with a cervical or high thoracic injury (T6 or higher).

The most common early symptom of a spinal cord tumor is a. urinary incontinence. b. back pain that worsens with activity. c. paralysis below the level of involvement. d. impaired sensation of pain, temperature, and light touch.

Correct answer: b Rationale: The most common early symptom of a spinal cord tumor is pain in the back, with radicular pain following the nerve(s) affected. The location of the pain depends on the level of compression. The pain worsens with activity, coughing, straining, and lying down. Later symptoms include paresthesia, paralysis, and impaired pain sensation. Neurogenic bowel and bladder are marked by incontinence, constipation, and urgency with difficulty in starting the flow, progressing to retention with overflow incontinence.

A patient undergoing rehabilitation for a C7 spinal cord injury tells the nurse he must have the flu because he has a bad headache and nausea. The nurse's first priority is to a. call the health care provider. b. check the patient's temperature. c. measure the patient's blood pressure. d. elevate the head of the bed to 90 degrees.

Correct answer: c Rationale: Autonomic dysreflexia is a massive, uncompensated cardiovascular reaction mediated by the sympathetic nervous system. It is important to measure BP first when a patient with a spinal cord injury reports a headache. Then, immediate nursing interventions include elevating the head of the bed 45 degrees to lower the blood pressure, determining the cause, and notifying the HCP. The nurse must monitor BP often during the episode. An α-adrenergic blocker or an arteriolar vasodilator may be given.

A patient undergoing rehabilitation for a C7 spinal cord injury tells the nurse he must have the flu because he has a bad headache and nausea. The nurse's first priority is to a. call the health care provider. b. check the patient's temperature. c. measure the patient's blood pressure. d. elevate the head of the bed to 90 degrees.

Correct answer: c Rationale: Autonomic dysreflexia is a massive, uncompensated cardiovascular reaction mediated by the sympathetic nervous system. It is important to measure BP first when a patient with a spinal cord injury reports a headache. Then, immediate nursing interventions include elevating the head of the bed 45 degrees to lower the blood pressure, determining the cause, and notifying the HCP. The nurse must monitor BP often during the episode. An α-adrenergic blocker or an arteriolar vasodilator may be given.

A patient with spinal cord injury has severe neurologic deficits. What is the most likely mechanism of injury for this patient? a. Compression b. Hyperextension c. Flexion-rotation d. Extension-rotation

Correct answer: c Rationale: The major mechanisms of injury include flexion, flexion-rotation, hyperextension, vertical compression, extension-rotation, and lateral flexion. The flexion-rotation injury is the most unstable because spinal ligaments are torn. This injury most often contributes to severe neurologic deficits.

A patient with spinal cord injury has severe neurologic deficits. What is the most likely mechanism of injury for this patient? a. Compression b. Hyperextension c. Flexion-rotation d. Extension-rotation

Correct answer: c Rationale: The major mechanisms of injury include flexion, flexion-rotation, hyperextension, vertical compression, extension-rotation, and lateral flexion. The flexion-rotation injury is the most unstable because spinal ligaments are torn. This injury most often contributes to severe neurologic deficits.

During routine assessment of a patient with Guillain-Barré syndrome, the nurse finds the patient is short of breath. The patient's respiratory distress is caused by a. elevated protein levels in the CSF. b. immobility resulting from ascending paralysis. c. degeneration of motor neurons in the brainstem and spinal cord. d. paralysis ascending to the nerves that stimulate the thoracic area.

Correct answer: d Rationale: Guillain-Barré syndrome is characterized by ascending, symmetric paralysis that usually affects cranial nerves and the peripheral nervous system. The most serious complication 60-3 Copyright © 2020 by Elsevier, Inc. All rights reserved. is respiratory failure. It occurs as the paralysis progresses to the nerves that innervate the thoracic area

During routine assessment of a patient with Guillain-Barré syndrome, the nurse finds the patient is short of breath. The patient's respiratory distress is caused by a. elevated protein levels in the CSF. b. immobility resulting from ascending paralysis. c. degeneration of motor neurons in the brainstem and spinal cord. d. paralysis ascending to the nerves that stimulate the thoracic area.

Correct answer: d Rationale: Guillain-Barré syndrome is characterized by ascending, symmetric paralysis that usually affects cranial nerves and the peripheral nervous system. The most serious complication is respiratory failure. It occurs as the paralysis progresses to the nerves that innervate the thoracic area.

During assessment of the patient with trigeminal neuralgia, the nurse should (select all that apply) a. inspect all aspects of the mouth and teeth. b. assess the gag reflex and respiratory rate and depth. c. lightly palpate the affected side of the face for edema. d. test for temperature and sensation perception on the face. e. ask the patient to describe factors that initiate an episode.

Correct answers: a, d, e Rationale: Assessment of the attacks, including the triggering factors, characteristics, frequency, and pain management techniques, helps the nurse plan for patient care. Painful episodes are usually triggered by light touch at a specific point (e.g., trigger zone) along the distribution of the nerve branches. Precipitating stimuli include chewing, tooth brushing, a hot or cold blast of air on the face, washing the face, yawning, or talking. Touch and tickle predominate as causative triggers, rather than pain or changes in ambient temperature. The nursing assessment should include the patient's nutritional status, hygiene (especially oral), and behavior (including withdrawal). Because of the attacks, the patient may eat improperly, neglect hygienic practices, wear a cloth over the face, and withdraw from interaction with others.

The nurse is caring for a patient with a spinal cord injury who demonstrates motor paralysis and a loss of pain and temperature sensation below the level of injury. The nurse suspects which causative factor of this condition? Damage to the central spinal cord Damage to the anterior spinal artery Damage to the posterior spinal artery Damage to one half of the spinal cord

Damage to the anterior spinal artery The causative factor for motor paralysis and loss of pain and temperature sensation is damage to the anterior spinal artery. Damage to the central spinal cord results in motor weakness and sensory loss in the upper and lower extremities. Loss of pain and temperature sensation below the level of injury is caused when one half of the spinal cord is damaged. Damage to the posterior spinal artery affects the dorsal column, which results in a loss of proprioception.

Which clinical manifestations of Guillain-Barré syndrome (GBS) are related to cranial nerve involvement? Select all that apply. Dysphagia Tachycardia Facial flushing Facial weakness Diaphoresis

Dysphagia Facial weakness Dysphagia and facial weakness occur due to cranial nerve involvement. Facial flushing and diaphoresis are manifestations of GBS that results from autonomic nervous system dysfunction. Autonomic nervous system dysfunction causes bradycardia, rather than tachycardia in patients with GBS.

Which symptoms are related to autonomic dysfunction in a patient with Guillain-Barré syndrome? Select all that apply. Dysrhythmias Bradycardia Paresthesia Hypotonia Orthostatic hypotension

Dysrhythmias Bradycardia Orthostatic hypotension The autonomic nervous system regulates nonvoluntary body functions such as heart rate and BP. In Guillain-Barré syndrome, autonomic dysfunction is common and usually takes the form of bradycardia, dysrhythmias, and orthostatic hypotension. Paresthesia and hypotonia (relaxed muscles) are symptoms of Guillain-Barré syndrome but are not related to autonomic dysfunction.

A patient with a spinal cord injury has a neurogenic bowel. Beyond the use of bisacodyl suppositories and digital stimulation, which measures should the nurse teach the patient and caregiver to assist with bowel evacuation? (Select all that apply.) Drink milk with each meal. Eat 20 to 30 g of fiber per day. Use an oral laxative every day. Limit intake of caffeinated beverages. Drink 1800 to 2800 mL of water or juice. Establish bowel evacuation time at bedtime.

Eat 20 to 30 g of fiber per day. Limit intake of caffeinated beverages. Drink 1800 to 2800 mL of water or juice. Rationale: The patient with a spinal cord injury and neurogenic bowel should eat 20 to 30 g of fiber and drink 1800 to 2800 mL of water or juice each day. Caffeine stimulates fluid loss and can contribute to constipation, so caffeine intake should be limited. Milk also may cause constipation. Daily oral laxatives may cause diarrhea and are avoided unless needed. Bowel evacuation time usually is established 30 minutes after the first meal of the day to take advantage of the gastrocolic reflex induced by eating.

Which intervention should the nurse perform first in the acute care of a patient with autonomic dysreflexia? Urinary catheterization Check for bowel impaction Elevate the head of the bed Administer intravenous hydralazine

Elevate the head of the bed Rationale: Positioning the patient upright is the first action so blood pressure will decrease. Then assessment of indwelling urinary catheter patency or immediate catheterization should be performed to relieve bladder distention. Next, the rectum should be examined for retained stool or impaction. Finally, the nurse will consider administering an intravenous antihypertensive medication if needed.

A 25-yr-old male patient has anterior spinal cord syndrome at T10. His history is significant for tobacco, alcohol, and marijuana use. What is the nurse's priority when planning for rehabilitation? Prevent urinary tract infection. Encourage him to share his feelings.Correct Answer Monitor the patient every 15 minutes. Teach him about using the gastrocolic reflex.

Encourage him to share his feelings. Rationale: To help the patient with coping and prevent self-harm, the nurse should create a therapeutic patient environment that encourages self-expression and verbalization of thoughts and feelings. The patient is at high risk for depression and self-injury because loss of function below the umbilicus is expected. He is a young adult male patient who will need a wheelchair and have impaired sexual function. Because the patient uses tobacco, alcohol, and marijuana frequently, hospitalization is likely to result in a loss of these habits and can make coping difficult. Preventing urinary tract infection and facilitating bowel evacuation with the gastrocolic reflex will be important during recovery. In rehabilitation, monitoring every 15 minutes is not needed unless the patient is on suicide precautions.

A patient with a spinal cord injury is paralyzed below the waist. The patient is completely dependent for all care, is withdrawn, and sleeps excessively. The patient tells the nurse, "I can't believe this is happening to me." How does the nurse respond? Select all that apply. Show sympathy towards the patient. Encourage the patient to set daily goals. Encourage the patient to participate in care. Explain the injury using written teaching material. Teach the patient what to expect during the rehabilitation period.

Encourage the patient to set daily goals. Encourage the patient to participate in care. Teach the patient what to expect during the rehabilitation period. Appropriate nursing actions include encouraging the patient to participate in care, allowing the patient to make daily goals, and teaching the patient what to expect during the rehabilitation process. The nurse should empathize with the patient. Sympathy is not a therapeutic action. Providing educational materials at this time is not appropriate; the nurse needs to address the patient's psychologic needs.

The nurse provides postoperative care for a patient after a cervical spine stabilization surgery. The nurse recognizes that which interventions will help stabilize the spine? Select all that apply. Avoid "logrolling" the patient. Ensure that the patient's body is correctly aligned. Use a sternal-occipital-mandibular immobilizer brace. Keep a soft cervical collar in place. Turn the patient as a unit.

Ensure that the patient's body is correctly aligned. Use a sternal-occipital-mandibular immobilizer brace. Turn the patient as a unit. Proper immobilization of the neck involves the maintenance of a neutral position. After cervical fusion or other stabilization surgery, the patient may have a hard cervical collar or sternal-occipital-mandibular immobilizer brace. The nurse should always keep the patient's body in correct alignment. The patient should be turned as a unit (e.g., logrolling) to prevent movement of the spine.

A patient with quadriplegia who has been hospitalized for one month is at a risk of developing pressure injury (PI). Which steps does the nurse take to prevent this complication? Select all that apply. Evaluate the nutritional status of the patient. Monitor urinary incontinence. Change the position of the patient every six hours. Avoid lifting the patient when changing the position. Check bony prominences for signs of pressure sores.

Evaluate the nutritional status of the patient. Monitor urinary incontinence. Check bony prominences for signs of pressure sores. Prevention of pressure ulcers and other types of injury to insensitive skin is essential for every patient with a spinal cord injury (SCI). Moisture from incontinence or any urine leakage can contribute to pressure ulcer development by macerating the skin and increasing friction injuries. Assess nutritional status regularly. A comprehensive visual and tactile examination of the skin should be done at least once daily, with special attention given to areas over bony prominences. The areas most vulnerable to breakdown include the ischia, trochanters, heels, and sacrum. Both body weight loss and weight gain can contribute to skin breakdown. When a patient is moved, it must be done in a way to prevent friction and shearing, because these forces will cause skin injury as readily as pressure. The patient must be lifted, not dragged, while repositioning, which also means that more than one person may be needed to move the patient. Pulling or dragging the patient will cause skin damage due to friction. Careful positioning and repositioning should be done every two hours.

Which health promotion activity has the greatest impact in the prevention of spinal cord injury (SCI) in adults 65 years and older? Hearing testing Depression screenings Fall prevention strategies Monitoring BP

Fall prevention strategies Falls are the leading cause of SCI in persons 65 years and older. Teaching patients to avoid climbing and using handrails on stairs are ways to prevent falls and injury. Hearing testing, depression screening, and BP monitoring are all ways to promote the health of persons 65 and older but do not prevent SCI directly.

How is Guillain-Barré syndrome (GBS) different from Bell's palsy? GBS affects cranial nerves. GBS is a mononeuropathy. GBS is a potentially fatal disorder. GBS results in demyelination of the nerve.

GBS is a potentially fatal disorder. GBS is a rapidly progressing and potentially fatal disorder. Bell's palsy is a benign disorder in which full recovery may occur in three to six months. Both disorders affect cranial nerves. GBS also affects the peripheral nervous system and is a polyneuropathy. Bell's palsy is a mononeuropathy. Both disorders may result in demyelination of the involved nerve.

Which assessment findings in a patient with a thoracic spinal cord injury (T4) would alert the nurse to possible autonomic dysreflexia? Headache and rising blood pressure Irregular respirations and shortness of breath Abdominal distention and absence of bowel sounds Decreased level of consciousness and hallucinations

Headache and rising blood pressure Rationale: Manifestations of autonomic dysreflexia are hypertension (up to 300 mm Hg systolic), a throbbing headache, bradycardia, and diaphoresis. Respiratory changes, decreased level of consciousness, and gastrointestinal problems are not characteristic manifestations.

When planning care for a patient with a cervical spinal cord injury (C5), which nursing problem has the highest priority? Constipation Difficulty coping Impaired breathing Impaired nutritional status

Impaired breathing Rationale: Maintaining a patent airway is the most important goal for a patient with a cervical spinal cord injury. Respiratory needs are always the highest priority (ABCs).

The nurse prepares a dietary teaching plan for a patient with a spinal cord injury and includes which information? Select all that apply. Include spicy food to improve taste. Include two servings from the milk group. Eat three well-balanced meals each day. Include beans in the diet to increase fiber intake. Include two or more servings from the meat group.

Include two servings from the milk group. Eat three well-balanced meals each day. Include two or more servings from the meat group. For maintaining adequate nutrition in the patient with spinal cord injury, the nurse should instruct the patient to eat three well-balanced meals per day. Food items should be included from the milk and the meat group to increase protein intake. Beans should be avoided because they can cause formation of gas. Spicy food should also be avoided because it can cause gastrointestinal upset.

The nurse prepares a home care plan for a patient with a T3 level complete spinal cord injury. The nurse recognizes which rehabilitation potential for this patient? Select all that apply. Independent self-care is possible. Independent wheelchair mobility is possible. The patient may be able to drive with hand controls. The patient will be able to climb stairs independently. The patient will be able to have independent standing in a standing frame.

Independent self-care is possible. Independent wheelchair mobility is possible. The patient may be able to drive with hand controls. The patient will be able to have independent standing in a standing frame. The patient with a T3 level spinal cord injury will have full innervation of the upper extremities, back, essential intrinsic muscles of the hands, full strength and dexterity of grasp, decreased trunk stability, and decreased respiratory reserve. Therefore, the patient may have the following potentials: full independence in self-care and in a wheelchair, ability to drive a car with hand controls, and independent standing in a standing frame. The patient will not able to climb stairs due to the injury.

A patient with a new cervical spinal cord injury is hospitalized. The nurse identifies that which interventions are appropriate to include in the patient's nutrition plan? Select all that apply. Insert a nasogastric tube. Evaluate swallowing before starting oral feeding. Prescribe a low-protein, low-carbohydrate diet. If oral feeding is not possible, enteral nutrition must be provided. Gradually introduce oral food and fluids, irrespective of bowel sounds.

Insert a nasogastric tube. Evaluate swallowing before starting oral feeding. If oral feeding is not possible, enteral nutrition must be provided. During the first 48 to 72 hours after the injury, the gastrointestinal (GI) tract may stop functioning (paralytic ileus), and hence a nasogastric tube should be inserted. In patients with high cervical cord injuries, evaluate swallowing before starting oral feedings. If the patient is unable to resume eating, then enteral nutrition may be used to provide nutritional support. Once bowel sounds are present or flatus is passed, gradually introduce oral food and fluids. Because of severe catabolism, a high-protein, high-calorie diet is necessary for energy and tissue repair.

A CT scan is prescribed for a patient with a spinal cord injury. When obtaining consent for the procedure, which explanations does the nurse provide? Select all that apply. It helps to find the exact location of injury. It helps to diagnose venous thromboembolism (VTE). It helps to assess changes in the neurologic tissue. It helps to find the degree of spinal canal compromise. It helps to find the presence of any damage to the spinal or vertebral arteries.

It helps to find the exact location of injury. It helps to find the degree of spinal canal compromise. . For a patient with spinal cord injury, a CT scan is the preferred imaging study to diagnose the location and degree of injury and degree of spinal canal compromise. An MRI is used to assess for soft-tissue and neurologic changes and for unexplained neurologic deficits or worsening of neurologic status. Patients with cervical injuries who demonstrate altered mental status may also need a CT angiogram to rule out vertebral artery damage. Duplex Doppler ultrasound, impedance plethysmography, venous occlusion plethysmography, venography, and the clinical examination are recommended for use as diagnostic tests for VTE.

The nurse is caring for a patient with a halo vest after cervical spine injury. Which care instructions should the nurse include in the patient's discharge plan? Keep a wrench close or attached to the vest. Use the frame and vest to assist in positioning. Clean around the pins using betadine swab sticks. Loosen both sides of the vest to provide skin care.

Keep a wrench close or attached to the vest. Rationale: A halo vest is used to provide cervical spine immobilization while vertebrae heal. There should always be a wrench with the halo vest in case emergency removal of the vest is needed (e.g., performance of CPR). Cleaning around the pins is typically performed with normal saline or chlorhexidine, based on provider instructions. Only one side of the vest can be loosened for skin care and changing clothes. After that side has been reattached, the other side of the vest can be loosened.

The nurse assists with prehospital care of a patient with a suspected C7 spinal cord injury. Which is the most important nursing intervention during this acute stage of care? Monitoring vital signs Maintaining a patent airway Maintaining proper body alignment Turning and repositioning the patient every two hours

Maintaining a patent airway Initial care for a patient with a C7 spinal cord injury is focused on establishing and maintaining a patent airway and supporting ventilation. Even though the injury is located at C7, spinal edema may extend to the C4 level and cause paralysis of the diaphragm. Therefore the effects and extent of edema are unpredictable, initially necessitating close monitoring of respiratory status. Monitoring the vital signs and maintaining proper body alignment are important nursing interventions but are not as high a priority as maintaining a patent airway. Turning and repositioning the patient every two hours depends on the stability of the spinal cord injury and the status of spinal precautions. A patient with a spinal cord injury may require a specialty bed or device.

A male patient with a T7 complete spinal cord injury (SCI) asks the nurse about sexual problems that he may experience. The nurse recalls which information related to sexual function that is associated with SCIs? Select all that apply. Men with complete injuries are less likely to have psychogenic erections. Most men with SCI can have a reflex erection with physical stimulation if the S2-S4 nerve pathways are not damaged. Signals from the brain about sexual thoughts are sent through the nerves of the spinal cord to the T10-L2 levels. The signals are then relayed to the penis and trigger an erection. The prognosis for men with SCI to father children is unlikely. Phosphodiesterase inhibitors have become the first-line treatment in men with SCI between T6 and L5.

Men with complete injuries are less likely to have psychogenic erections. Most men with SCI can have a reflex erection with physical stimulation if the S2-S4 nerve pathways are not damaged. Signals from the brain about sexual thoughts are sent through the nerves of the spinal cord to the T10-L2 levels. The signals are then relayed to the penis and trigger an erection. Phosphodiesterase inhibitors have become the first-line treatment in men with SCI between T6 and L5. Men with complete injuries are less likely to experience psychogenic erections. Most men with SCI can have a reflex erection with physical stimulation if the S2-S4 nerve pathways are not damaged. The process of psychogenic erection begins in the brain with sexual thoughts. Signals from the brain are sent through the nerves of the spinal cord to the T10-L2 levels. The signals are then relayed to the penis and trigger an erection. Phosphodiesterase inhibitors (e.g., sildenafil [Viagra]) have become the first-line treatment in men with SCI between T6 and L5. Recent advances in sperm retrieval techniques have changed the prognosis for men with SCI to father children from unlikely to a reasonable chance of successful outcomes.

The nurse is assessing a patient with a T2 level spinal cord injury (SCI). The nurse notes that there is a kink in the catheter, the bladder is distended, and the BP is 220/100 mm Hg. Which interventions does the nurse implement? Select all that apply. Lower the head of the bed. Monitor BP regularly. Place the patient in a flat-lying position. Notify the primary health care provider. Check for the presence of bowel impaction. Remove the kink in the catheter and drain the bladder.

Monitor BP regularly. Notify the primary health care provider. Check for the presence of bowel impaction. Remove the kink in the catheter and drain the bladder. The patient is evidencing signs of autonomic dysreflexia (AD), which is a massive, uncompensated cardiovascular reaction mediated by the sympathetic nervous system (SNS). It involves stimulation of sensory receptors below the level of the SCI. The intact SNS below the level of injury responds to the stimulation with a reflex arteriolar vasoconstriction that increases BP. Nursing interventions in a serious emergency like AD include notifying the primary health care provider and determining the cause. The BP should be regularly monitored; administration of an α-adrenergic blocker or an arteriolar vasodilator is required. Contractions of the rectum are also a cause; therefore, the nurse should check for bowel impaction and treat it accordingly. The most common cause is bladder distention. If a catheter is present, then the presence of any kinks or folds should be checked. However, the most important nursing intervention in this case is elevating the head of the bed 45 degrees or higher to make the patient sit upright; this would lower the BP.

The nurse provides care for a patient immediately after a spinal cord injury (SCI). The nurse identifies that which renal problems can occur because of the loss of autonomic and reflex control of the bladder? Select all that apply. Overdistention of the bladder Renal failure Rupture of the bladder No sensation of bladder fullness Infection

Overdistention of the bladder Renal failure Rupture of the bladder No sensation of bladder fullness Immediately after the injury, urine retention occurs because of the loss of autonomic and reflex control of the bladder and sphincter (neurogenic bladder). Because there is no sensation of fullness, overdistention of the bladder can result in reflux into the kidney and cause renal failure. Bladder overdistention may even result in rupture of the bladder. The patient is at risk for an infection after a catheter is inserted.

The nurse performs a respiratory assessment on a patient with uncomplicated tetraplegia and identifies that which finding is acceptable? PaO2 >60 mm Hg PaCO2 <55 mm Hg Respiratory rate 30 breaths/minute Bibasilar crackles

PaO2 >60 mm Hg A PaO2 >60 mm Hg and a PaCO2 <45 mm Hg are acceptable values in a patient with uncomplicated tetraplegia. A respiratory rate of 30 is tachypnea, which is not an acceptable finding. When bibasilar crackles are auscultated, the nurse should evaluate the patient for the need to be suctioned.

A patient who is hospitalized with a T10 spinal cord injury experiences neurogenic bowel. Which intervention does the nurse include in the patient's bowel management program? Encourage the use of the Valsalva maneuver. Administer an oral stimulant laxative regularly. Encourage the patient to drink a cold beverage right after the meal. Plan bowel evacuation for 30 to 60 minutes after the first meal.

Plan bowel evacuation for 30 to 60 minutes after the first meal. Planning bowel evacuation for 30 to 60 minutes after the first meal of the day may enhance success by taking advantage of the gastrocolic reflex induced by eating. Because the Valsalva maneuver requires intact abdominal muscles, it is used in patients with injuries below T12. Oral stimulant laxatives should be used only if absolutely necessary and not on a regular basis. The gastrocolic reflex may also be stimulated by drinking a warm beverage right after the meal.

Which information is an important part of the health history for a patient with a new diagnosis of Guillain-Barré syndrome (GBS)? Recent viral infection Family history of GBS Exposure to others with GBS 4 Immunization within last 30 days

Recent viral infection. Although the cause of GBS is unknown, most cases occur after a viral or bacterial infection of the upper respiratory or gastrointestinal tract. GBS is not hereditary, nor does one develop the disorder from exposure to others with GBS. Immunizations do not cause GBS.

Which body system is the priority focus for nursing care of the patient with Guillain-Barré syndrome? Urinary Cardiac Respiratory Gastrointestinal

Respiratory Guillain-Barré syndrome is an autoimmune disease that destroys the myelin sheath covering peripheral nerves. Symptoms range from mild to severe, potentially as far as full-body paralysis. Frequently, the muscles controlling respiratory function are affected, resulting in respiratory failure. The disease causes rapid, progressive, symmetrical loss of motor function that ascends from the extremities to the head. Although Guillain-Barré syndrome may affect some functions of the urinary, cardiac, and gastrointestinal systems, respiratory status is most important for the nurse to monitor.

Which assessment is a priority when caring for a patient who has been diagnosed with Guillain-Barré syndrome? Pain assessment Glasgow Coma Scale Respiratory assessment Musculoskeletal assessment

Respiratory assessment In the case of patients with Guillain-Barré syndrome, the acute risk of respiratory failure necessitates vigilant monitoring of the patient's respiratory status. Pain and musculoskeletal assessment are important for the patient with Guillain-Barré syndrome but are not a priority. The Glasgow Coma Scale also is important in assessing the neurologic status of the patient, but it is not a priority.

The nurse is providing care for a patient diagnosed with Guillain-Barré syndrome. Which assessment should be the nurse's priority? Pain assessment Glasgow Coma Scale Respiratory assessment Musculoskeletal assessment

Respiratory assessment Rationale: Although all the assessments are necessary in the care of patients with Guillain-Barré syndrome, the acute risk of respiratory failure requires vigilant monitoring of the patient's respiratory function.

The respiratory status of a patient with Guillain-Barré syndrome is deteriorating. Which nursing interventions would be performed for this patient? Select all that apply. Obtain prescription for steroid inhaler. Administer bronchodilators, as prescribed. Send a sputum culture if patient is febrile. Keep necessary equipment ready for mechanical ventilation and tracheostomy. Monitor vital capacity and arterial blood gases (ABGs).

Send a sputum culture if patient is febrile. Keep necessary equipment ready for mechanical ventilation and tracheostomy. Monitor vital capacity and arterial blood gases (ABGs). This patient is highly likely to develop respiratory infections. If fever develops, obtain sputum cultures to identify the pathogen. Appropriate antibiotic therapy is then initiated. The most serious complication is respiratory failure, which occurs as the paralysis progresses to the nerves that innervate the thoracic area. Monitoring the vital capacity and ABGs is essential. If the vital capacity drops to less than 800 mL or the ABGs deteriorate, then endotracheal intubation or tracheostomy may be done so that the patient can be mechanically ventilated. Administration of bronchodilators or steroids will not improve the condition of the patient because the respiratory failure is being caused by the paralysis of respiratory muscles.

The nurse reviews the medical record of a patient with poikilothermia. The nurse identifies that which history finding likely caused this condition? Polyneuropathy Spinal cord injury Spinal cord tumor Cranial nerve disorder

Spinal cord injury Poikilothermia is the inability to maintain body temperature. It is one of the manifestations of spinal cord injury. Polyneuropathies may result in weakness of the lower extremities, paresthesia (numbness and tingling), paralysis with muscle incoordination and weakness, stiffness in the jaw and neck, sharp pains in the leg, and ataxia. A spinal cord tumor may result in back pain, coldness, numbness, and tingling in the extremities. Cranial nerve disorders usually result in burning, knifelike, or lightning-like shock in the lips; intense pain, twitching, tinnitus, paralysis of the motor branches of the facial nerve; and drooping of the mouth accompanied by drooling.

Which criteria are used to determine whether plasmapheresis is effective in a patient who is diagnosed with Guillain-Barré syndrome? Select all that apply. Urinary output is at least 30 mL/hr. Stabilization of BP and pulse rate. Symptoms of paralysis stop progressing and abate. Lung vital capacity and arterial blood gases are stable. Blood urea nitrogen (BUN) and creatinine levels are within normal levels.

Stabilization of BP and pulse rate. Symptoms of paralysis stop progressing and abate. Lung vital capacity and arterial blood gases are stable. Guillain-Barré syndrome is a polyneuropathic condition resulting from an immune response following some type of infection. Symptoms include paresthesia with ascending bilateral paralysis as demyelination of the nerves occurs. The paralysis starts in the extremities and can advance to the thoracic area, resulting in respiratory failure. Disturbance in the autonomic nervous system causes episodes of hypotension, hypertension, and bradycardia. Treatment is successful with the halt of paralysis and stabilization of cardiovascular function and respiratory status. BUN and creatinine levels and urinary output are measures of renal function.

A patient with paraplegia experiences convulsive movements of the lower limbs. Which information does the nurse provide to the patient and the caregivers about the spasms? Select all that apply. The spasms can occur as a result of a variety of stimuli. This occurs due to hyperexcitability of the upper motor neuron. The spasms indicate improvement in the condition of the patient. Such reflexes could be positively used for bowel and bladder retraining. Medications such as baclofen or dantrolene may be prescribed to help to control the spasms.

The spasms can occur as a result of a variety of stimuli. Such reflexes could be positively used for bowel and bladder retraining. Medications such as baclofen or dantrolene may be prescribed to help to control the spasms. Once the period of spinal shock is resolved, due to lack of control from the higher brain centers, reflexes are often hyperactive and produce exaggerated responses. Spasms ranging from mild twitches to convulsive movements below the level of injury may also occur. These may occur due to a variety of stimuli. These reflexes are useful in sexual, bowel, and bladder retraining. Antispasmodic drugs, such as baclofen, dantrolene, and tizanidine, may help control spasms. The upper motor neuron does not have an inhibitory control over the lower motor neuron. These spasms do not indicate an improvement in the condition of the patient.

A patient who has been admitted to the hospital with a spinal cord injury at the upper thoracic level experiences neurogenic shock. How does the nurse explain the condition to the patient's family? Select all that apply. The BP and heart rate have increased. The blood vessels in the extremities have constricted. There is loss of nervous control of the blood vessels. The amount of blood pumped out of the heart is reduced. There is pooling of blood in the veins of the extremities.

There is loss of nervous control of the blood vessels. The amount of blood pumped out of the heart is reduced. There is pooling of blood in the veins of the extremities. Neurogenic shock is due to the loss of vasomotor tone caused by spinal cord injury. Loss of sympathetic nervous system innervation causes peripheral vasodilation, venous pooling, and decreased cardiac output. It is chiefly characterized by hypotension and bradycardia, not increased BP and heart rate. The blood vessels in the extremities dilate due to neurogenic shock.

The nurse is caring for a patient who has sustained a spinal cord injury. To prevent autonomic dysreflexia, the nurse instructs the patient to avoid which occurrence? Urine retention Emotional stress Exposure to secondhand smoke Being in contact with people with upper respiratory infections

Urine retention Autonomic dysreflexia is a medical emergency that occurs when sensory stimulation below the spinal injury triggers a reaction in the intact autonomic system, with resulting reflex arteriolar spasms that increase BP to an extremely high level. A distended bladder is a common trigger of this condition. Profuse sweating below the level of injury and bradycardia are also seen. Although emotional stress, being exposed to secondhand smoke, and exposure to upper respiratory infections should be avoided by the patient with a spinal cord injury, these factors do not trigger autonomic dysreflexia.

A patient with a T1 level spinal cord injury (SCI) is scheduled to be discharged from the hospital. The nurse creates a neurogenic bowel management plan and includes which information? Select all that apply. Use of the Valsalva maneuver Use of stool softeners Dietary choices for a high-fiber diet Fluid restriction guidelines Use of suppositories for evacuation Instructions for how to perform digital stimulation of the rectum

Use of stool softeners Dietary choices for a high-fiber diet Use of suppositories for evacuation Instructions for how to perform digital stimulation of the rectum Careful management of bowel evacuation is necessary in the patient with SCI because voluntary control of this function may be lost. This condition is called neurogenic bowel. A stool softener such as docusate sodium can be used to regulate stool consistency. A digital stimulation (performed 20 to 30 minutes after suppository insertion) by the nurse or patient may be necessary. In addition, suppositories (bisacodyl or glycerin) or small-volume enemas can be used. The usual measures for preventing constipation include a high-fiber diet and adequate fluid intake. However, these measures by themselves may not be adequate to stimulate evacuation. The Valsalva maneuver requires intact abdominal muscles, so it is used in those patients with injuries below T12. A high intake of fluid is advised for easier bowel evacuation.

Which interventions does the nurse include in the teaching plan for a patient with paraplegia who is being discharged from a rehabilitation facility? Select all that apply. Use pressure-relief devices while sitting. Change bed positions at least every two hours. Apply massage to areas with sustained redness. Follow a diet high in vitamins and low in protein. Dress warmly in cold weather to prevent frostbite.

Use pressure-relief devices while sitting. Change bed positions at least every two hours. Dress warmly in cold weather to prevent frostbite. Prevention of skin breakdown is the goal for patients with paraplegia (paralysis of the lower extremities). Because patients sit much of the time, pressure relief devices are needed, especially on wheelchairs. Skin that remains reddened after 30 minutes is showing signs of pressure damage. Minimally, patients need to change position every two hours to prevent pressure sore development. The patient should dress warmly in cold weather to prevent frostbite. Massaging the areas will add to the injury. A diet with adequate vitamins and adequate protein is needed to maintain skin integrity.

Which statement is accurate about Guillain-Barré syndrome (GBS)? Pain is generally worse during the day. People younger than 40 years of age are at greatest risk. Heart failure (HF) is the most serious complication of this condition. Weakness of the limbs is acute and symmetrical.

Weakness of the limbs is acute and symmetrical. The main features of GBS include acute, ascending, rapidly progressive, symmetric weakness of the limbs. The pain, which is manifested by paresthesias, is generally worse at night. GBS can affect anyone, but people older than 50 years of age are at greatest risk. The most serious complication is respiratory failure.

The nurse is caring for a patient admitted with a spinal cord injury after a motor vehicle accident. The patient has a complete loss of motor, sensory, and reflex activity below the injury level. The nurse recognizes this condition as: central cord syndrome. spinal shock syndrome. anterior cord syndrome. Brown-Séquard syndrome.

spinal shock syndrome. Rationale: About 50% of people with acute spinal cord injury develop spinal shock, a temporary loss of reflexes, sensation, and motor activity. Central cord syndrome is manifested by motor and sensory loss greater in the upper extremities than the lower extremities. Anterior cord syndrome results in motor and sensory loss but not loss of reflexes. Brown-Séquard syndrome is characterized by ipsilateral loss of motor function and contralateral loss of sensory function.