Nursing - 309 Neuro Quiz I

The Rn is taking a history on an older adult pt who reports chronic back pain. The Rn 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?"

You are preparing to discharge a client with chronic low back pain. Which statement by the client indicates the need for additional teaching?

"I will avoid exercise because the pain gets worse."

The Rn reviews the discharge and home care instructions with a pt who had back surgery. Which statement by the pt indicates further teaching is needed?

"I will drive myself to my doctor's office next week."

A pt has been talking to this physician about drugs that could potentially be used in the treatment of acute low back pain. Which statement by the pt 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."

Because the pt is at risk for spinal shock, what does the RN monitor for?

Decreased blood pressure, bradycardia, and decreased bowel sounds.

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

Semi Fowler's position with a pillow under the knees to keep them flexed.

For which clinical indicator should the RN assess a pt who just had a microdiskectomy for a herniated lumbar disk?

Sensory loss in legs.

The Rn is caring for a pt with a SCI who is experiencing neurogenic shock. The pt's systolic blood pressure is 88 mm/Hg despite starting a dopamine drip 2 hours earlier. There is a new order to infuse 500 mL of Dextran-40 over 4 hours. At what rate does the Rn set the infusion pump?

125 mL/hr

The Rn is preparing to physically assess a pt's subjective report of paresthesia in the lower extremities. In order to accomplish this assessment, which assessment technique does the RN use?

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

A pt 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 pt involved in a hihg speed motor vehicle accident with sustained multiple injuries and active bleeding is transported to the ED by ambulance with immobilization devices in place. There is a high probability of cervical spine fracture; the pt has altered mental status and extremities are flaccid. What is the priority assessment for this pt?

Assess the respiratory pattern and ensure a patent airway.

What does the RN do for a pt with a cervical laminectomy that differes from the nursing care for a pt with a lumbar laminectomy?

Assist with the removal of oral secretions.

A pt with a cervical SCI has been placed in fixed skeletal traction with a halo fixation device. When caring for this pt, the RN may delegate which action to a LPN?

Checking the pt's neurologic status for changes. Observing the halo insertion sites for signs of infection. Cleaning the halo insertion sites with hydrogen peroxide.

A RN expects a pt with a herniated intervertebral disk to report report a sudden increase in pain with which activities?

Coughing or sneezing. Straining when having a bowel movement.

A pt with an SCi has paraplegia and paraparesis. The Rn has identified a priority pt problem of inability to ambulate. The RN assesses the calf area of both legs for swelling, tenderness, redness, or possible complaints of pain. This assessment is specific to the pt's increased risk for which condition?

Deep vein thrombosis

The Rn is caring for a pt who has been in a long term care facility for several months following an SCI. The pt has had problems with urinary retention and subsequent overflow incontinence, and a bladder retraining 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 Rn is providing discharge teaching for a pt with a SCI who will be performing intermittent self-catheterizations at home. Which signs and symptoms will the RN instruct the pt to report immediately to the primary health care provider?

Fever Foul smelling urine

A pt has a functional transection of the spinal cord at C7-8, resulting in spinal shock. Which clinical indicators does the RN expect to identify when assessing the pt immediately after the injury?

Flaccid paralysis Lack of reflexes below the injury.

Which symptoms indicate that a pt with a SCI is experiencing autonomic dysreflexia?

Hypertension Severe headache blurred vision

What is a potential adverse outcome of autonomic dysreflexia in a pt with a SCI?

Hypertensive stroke

You are preparing a nursing care plan for a pt with an SCI for whom the nursing diagnoses of Impaired Physical Mobility and Toileting Self-Care Deficit have been identified. The pt tells you, "I don't know why we're doing all this. My life's over." Based on this statement, which additional nursing diagnosis takes priority?

Impaired Individual Resilience related to spinal cord injury.

Which statements about spinal shock are accurate?

It lasts for less than 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 Rn finds a victim under the wreckage of a collapsed building. The individual is conscious, supine, breathing satisfactorily, and reporting back pain and an inability to move the legs. Which action should the RN take FIRST?

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

A pt with quadriplegia is placed on a tilt table daily. Each day the angel of the head of the table gradually is increased. What should the RN identify as its purpose when the pt asks the reason for the tile table?

Limits loss of calcium from the bones.

A pt has just undergone spinal fusion surgery and returned form the operating room 12 hours ago. Which task is best to delegate to the UAP?

Log roll the pt every 2 hours.

The Rn is caring for several pt with SCIs. Which task is best to delegate to the UAP?

Log roll the pt; maintain proper body alignment and place a bedpan for toileting.

The Rn is caring for a pt with a recent SCI. Which intervention does the Rn use to target and prevent the potential SCI complication of autonomic dysreflexia?

Loosen or remove any tight clothing. Monitor stool output and maintain a bowel program. Monitor urinary output and check for bladder distention.

After a pt is treated for SCI, the health care provider informs the family that the pt is a paraplegic. The family asks the RN what this means. What explanation should the RN provide?

Lower extremities are paralyzed.

A pt with an SCI at level C3-C4 is being cared for in the ED. What is the priority assessment?

Monitor respiratory effort and O2 Sat

The pt with chronic back pain is receiving ziconotide (Prialt) by intrachecal infusion with a surgically implanted pump. The pt develops hallucinations. What is the RN's best first action?

Notify the health care provider

Which clinical indicator does the Rn expect to identify when assessing a pt admitted with a herniated lumbar disk?

Pain radiating to the hip and leg.

Assessment of a pt with a lower spinal cord injury confirms that the pt has paralysis of the bilateral lower extremities. How does the RN document this finding?

Paraplegia

The Rn is assessing a pt who presented to the ED reporting acute onset of numbness and tingling in the right leg. How does the RN document this subjective finding?

Paresthesia

A pt has paraplegia as a result of a motorcycle accident. What is the reason the RN care plan should include turning the pt every 1 to 2 hours?

Prevent pressure ulcers.

A Rn should expect a pt with a SCI to have some spasticity of the lower extremities. What should the RN include in the plan of care for this pt to prevent the development of lower extremity contractures?

Proper positioning

The RN is assessing a pt with a SCI and recognizes that the pt is experiencing autonomic dysreflexia. What is the RN's first priority action?

Raise the head of the bed.

What should the RN include in the plan of care for a pt who just had a posterior lumbar laminectomy?

Reposition the pt by log rolling.

After suffering an SCI, a pt develops autonomic dysfunction, including a neurogenic bladder. What is the priority pt problem for this condition?

Risk for UTI

A pt has a long history of chronic back pain and has undergone several back surgeries in the past. At this point, the surgeon is recommending a surgical procedure for spine stabilization. Which procedure does the RN anticipate this pt will need?

Spinal fusion

After a traumatic spinal cord severance, a young pt is having difficulty accepting the paralysis. One day the pt has severe leg spasms and says, "My strength is coming back and I know I will walk again." The Rn's response should be based on what understanding?

Spinal shock has subsided and the pt's reflexes are hyperactive.

You are helping a client with an SCI to establish a bladder retraining program. Which strategies may stimulate the pt to void?

Stroking the pt's inner thigh. Pulling on the pt's pubic hair. Pouring warm water over the pt's perineum Tapping the bladder to stimulate the detrusor muscle.

What should the RN assess for when a pt with a cervical injury reports a severe headache and nasal congestion?

Suprapubic distention

A pt has just undergone a laminectomy and returned from surgery at 1300 hours. At 1530 hours, the RN is performing the change of shift assessment. Which postoperative findings are reported to the surgeon immediately?

Swelling or bulging at the operative site. Moderate clear drainage on the postoperative dressing.

A pt has just undergone a spinal fusion and 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 a neurologic 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.

You are floated form the ED to the Neurologic floor. Which action should you delegate to the UAP when providing nursing care for a pt with SCI?

Taking the pt's vital signs and recording every 4 hours

A pt is scheduled for lumbar surgery. Which key points must the RN include in a preoperative teaching plan for this pt?

Techniques for getting in and out of bed. Expectations for turning and moving in bed Limitations and restrictions for home activities Report any numbness and tingling to the nurse immediately.

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

They usually will never walk.

Which neurologic assessment technique does the Rn use to test a pt for sensory function?

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

The Rn and the nursing student are working together to bathe and reposition a pt who is in a halo fixator device. Which action by the nursing student needs intervention?

Turns the pt by pulling on the top of the halo device.

What problem is the RN primarily attempting to prevent when encouraging a pt with a SCI to increase oral fluid intake?

Urinary Tract Infection.

A pt with a SCI has paraplegia. The RN assesses for which major problem the pt may experience early in the recovery period?

bladder control

A pt with a spinal cord injury (SCI) reports sudden severe throbbing headache that started a short time ago. Assessment of the client reveals increased blood pressure (169/94) and decreased heart rate (48 bpm), diaphoresis, and flushing of the face and neck. What action should you take first?

check the Foley tubing for kinks or obstruction.

The Rn is preparing a quadriplegic pt for discharge and has taught the pt's spouse to assist the pt 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 pt's diaphragm and pushes upward as the pt exhales.