Test Review. Module 1. Advanced Med Surg.

A young adult is hospitalized after an accident that resulted in a complete transection of the spinal cord at the level of C7. The nurse informs the patient that after rehabilitation, the level of function that is most likely to occur is the ability to a. breathe with respiratory support. b. drive a vehicle with hand controls. c. ambulate with long-leg braces and crutches. d. use a powered device to handle eating utensils.

Answer: B Rationale: A patient with injury at the level of C7 to C8 may have the following rehabilitation potential: ability to transfer self to wheelchair; roll over and sit up in bed; push self on most surfaces; perform most self-care; use wheelchair independently; and drive a car with powered hand controls (in some patients); attendant care 0 to 6 hours/day.

A patient is just admitted to the hospital following a spinal cord injury at the level of T4. A priority of nursing care for the patient is monitoring for a.return of reflexes. b.bradycardia with hypoxemia. c.effects of sensory deprivation. d.fluctuations in body temperature.

Answer: B Rationale: Neurogenic shock is due to loss of vasomotor tone caused by injury and is characterized by hypotension and bradycardia, which are important clinical clues. Loss of sympathetic nervous system innervation causes peripheral vasodilation, venous pooling, and decreased cardiac output. These effects are generally associated with a cervical or high thoracic injury (T6 or higher). Injury or fracture below the level of C4 results in diaphragmatic breathing if the phrenic nerve is functioning.

A patient in neurogenic shock is ordered intravenous fluids due to severe hypotension. During administration of the fluids the nurse will monitor the patient closely and immediately report? A. Increase in blood pressure B. High central venous pressure (CVP) and pulmonary artery wedge pressure (PAWP) C. Urinary output of 300 mL in the past 5 hours D. Mean arterial pressure (MAP) 85 mmHg

Answer: B. Rationale: Option B would indicate the patient is in fluid volume overload. Remember that patients in neurogenic shock usually have a normal blood volume. If fluids are ordered to help increase the blood pressure, they should be used with extreme caution because fluid overload can occur. An increase in the CVP and PAWP would indicate this. These pressures show the filling pressure in the heart.

Which patient below is at MOST risk for developing a condition called autonomic dysreflexia? A. A 24-year-old male patient with a traumatic brain injury. B. A 15-year-old female patient with a spinal cord injury at C7. C. A 35-year-old male patient with a spinal cord injury at L6. D. A 42-year-old male patient recovering from a hemorrhagic stroke.

Answer: B. Rationale: Patients who are at MOST risk for developing autonomic dysreflexia are patients who've experienced a spinal cord injury at T6 or higher...this includes C7. L6 is below T6, and traumatic brain injury and hemorrhagic stroke does not increase a patient risk of AD.

During assessment of a patient with a spinal cord injury at the level of T2 at the rehabilitation center, which finding would concern the nurse the most? a. A heart rate of 92 b. A reddened area over the patient's coccyx c. Marked perspiration on the patient's face and arms d. A light inspiratory wheeze on auscultation of the lungs

Answer: C Rationale: Autonomic dysreflexia is a massive uncompensated cardiovascular reaction mediated by the sympathetic nervous system. It occurs in response to visceral stimulation once spinal shock is resolved in patients with spinal cord lesions. The condition is a life-threatening situation that requires immediate resolution

The physician orders Nitropaste for a patient who has developed autonomic dysreflexia. Which finding would require the nurse to hold the ordered dose of Nitropaste and notify the physician? A. The patient's blood pressure is 130/80. B. The patient reports a throbbing headache. C. The patient's lower extremities are pale and cool. D. The patient states they took Sildenafil 12 hours ago.

Answer: D Rationale: A patient should not receive a dose of Nitropaste if they have taken a phosphodiesterase inhibitor within the past 24 hours (Sildenafil or Tadalafil). This will cause major vasodilation and severe hypotension that will not respond to medication. Another medication should be used. All the other findings are expected with autonomic dysreflexia.

The nurse is about to assess for bowel impaction in a patient who has developed autonomic dysreflexia. The nurse makes it priority to? A. Avoid using lubricants B. Stimulate the bowel with rectal manipulation C. Slowly administer a saline solution prior to assessment D. Instill an anesthetic jelly prior to assessment

Answer: D Rationale: To avoid increasing autonomic dysreflexia symptoms by increasing the sympathetic reflex due to an irritating stimulus, the nurse should instill an anesthetic jelly before assessing the rectum for hardened stool. This is also important prior to catheterization to check the bladder for urine.

Guillain-Barré Syndrome occurs when the body's immune system attacks the myelin sheath on the nerves in the central nervous system. True False

Answer: FALSE Rationale: Guillain-Barré Syndrome is an autoimmune neuro condition where the immune system attacks the nerves (myelin sheath) in the PERIPHERAL NERVOUS SYSTEM and cranial nerves. This condition does NOT occur in the central nervous system (CNS).

True or False: The parasympathetic nervous system loses the ability to stimulate nerve impulses in patients who are experiencing neurogenic shock. This leads to hemodynamic changes. True False

Answer: FALSE Rationale: the statement should say: The sympathetic (NOT parasympathetic) nervous system loses the ability to stimulate nerve impulses in patients who are experiencing neurogenic shock. This leads to hemodynamic changes.

The patient's lumbar puncture results are back. Which finding below correlates with Guillain-Barré Syndrome? A. high glucose with normal white blood cells B. high protein with normal white blood cells C. high protein with low white blood cells D. low protein with high white blood cells

The answer is B

A patient is receiving treatment for a complete spinal cord injury at T4. As the nurse you know to educate the patient on the signs and symptoms of autonomic dysreflexia What signs and symptoms will you educate the patient about? Select all that apply: A. Headache B. Low blood glucose C. Sweating D. Flushed below site of injury E. Pale and cool above site of injury F. Hypertension G. Slow heart rate H. Stuffy nose

The answers are A, C, F, G and H. Rationale: All of these are signs and symptoms of autonomic dysreflexia. The patient will have flushing above site of injury due to vasodilation from parasympathetic activity, BUT will be pale and cool below site of injury due to vasoconstriction occurring below the site of injury for the sympathetic response reflex.

You're developing a nursing plan of care for a patient with neurogenic shock. As the nurse, you know that due to venous blood pooling from vasodilation a deep vein thrombosis can occur in this type of shock. A patient goal is that the patient will be free from the development of a deep vein thrombosis. Select all the nursing interventions below that can help the patient meet this goal: A. Perform range of motion exercises daily. B. Place a pillow underneath the patient knees as needed. C. Administer anticoagulants as scheduled per physician's order. D. Apply compression stockings daily.

The answers are A, C, and D. Rationale: Option B would impede blood flow and increase the risk of a DVT. The other options would help prevent a DVT.

You receive a patient in the ER who has sustained a cervical spinal cord injury. You know this patient is at risk for neurogenic shock. What hallmark signs and symptoms, if experienced by this patient, would indicate the patient is experiencing neurogenic shock? Select all that apply: A. Blood pressure 69/38 B. Heart rate 170 bpm C. Blood pressure 250/120 D. Heart rate 29 E. Warm and dry extremities F. Cool and clammy extremities G. Temperature 104.9 'F H. Temperature 95 'F

The answers are A, D, E, and H. Rationale: Hallmark signs and symptoms of neurogenic shock are: hypotension, bradycardia, hypothermia, warm/dry extremities (this is due to the vasodilation and blood pooling and will be found in the extremities).

You're working on a neuro unit. Which of your patients below are at risk for developing neurogenic shock? Select all that apply: A. A 36-year-old with a spinal cord injury at L4. B. A 42-year-old who has spinal anesthesia. C. A 25-year-old with a spinal cord injury above T6. D. A 55-year-old patient who is reporting seeing green halos while taking Digoxin.

The answers are B and C. Rationale: Any patient who has had a cervical or upper thoracic (above T6) spinal cord injury, receiving spinal anesthesia, or taking drugs that affect the autonomic or sympathetic nervous system is at risk for developing neurogenic shock.

Your patient is back from having a lumbar puncture. Select all the correct nursing interventions for this patient? A. Place the patient in lateral recumbent position. B. Keep the patient flat. C. Remind the patient to refrain from eating or drinking for 4 hours. D. Encourage the patient to consume liquids regularly.

The answers are B and D. Rationale: The patient will need to stay flat after the procedure for a prescribed amount of time to prevent a headache, and the nurse will need to encourage the patient to drink fluids regularly to help replace the fluid lost during the lumbar puncture.

Which tests below can be ordered to help the physician diagnose Guillain-Barré Syndrome? Select all that apply: A. Edrophonium Test B. Sweat Test C. Lumbar puncture D. Electromyography E. Nerve Conduction Studies

The answers are C, D, and E. Rationale: These are the tests that can be ordered to help the MD determine if the patient is experiencing GBS.

You administer the Confusion Assessment Method (CAM) tool to K.P. to differentiate among various cognitive disorders, primarily because a. delirium can be reversed by treating the underlying causes. b. depression is a common cause of dementia in older adults. c. nursing care should be based on the cause of the cognitive impairment. d. drug therapy with antipsychotic agents is indicated in the treatment of dementia.

Answer: A Rationale: Delirium, a state of temporary but acute mental confusion, is a common, life-threatening, and possibly preventable syndrome in older adults. Clinically, delirium is rarely caused by a single factor. It is often the result of the interaction of the patient's underlying condition with a precipitating event.

What is the BEST position for a patient experiencing autonomic dysreflexia? A. High Fowler's with legs lowered B. Low Fowler's with legs lowered C. Semi-Fowler's with legs at heart level D. Prone

Answer: A. Rationale: The patient should be in high Fowler's (90 degrees) with the legs lowered. This will allow gravity to cause blood to pool in the lower extremities and help decrease blood pressure.

Your patient in neurogenic shock is not responding to IV fluids. The patient is started on vasopressors. What option below, if found in your patient, would indicate the medication is working? A. Decreased CVP (central venous pressure) B. Mean arterial pressure (MAP) 90 mmHg C. Serum lactate 6 mmol/L D. Blood pH 7.20

Answer: B. Rationale: A MAP of 85-90 mmHg will help maintain tissue perfusion and indicates the vasopressor is working to maintain tissue perfusion. It does this by causing vasoconstriction. Options A, C, and D would indicate tissue perfusion is decreased.

You're educating a patient about treatment options for Guillain-Barré Syndrome. Which statement by the patient requires you to re-educate the patient about treatment? A. "Treatments available for this syndrome do not cure the condition but helps speed up recovery time." B. "Plasmapheresis or immunoglobin therapies are treatment options available for this syndrome but are most effective when given within 4 weeks of the onset of symptoms." C. "When I start plasmapheresis treatment a machine will filter my blood to remove the antibodies from my plasma that are attacking the myelin sheath." D. "Immunoglobulin therapy is where IV immunoglobulin from a donor is given to a patient to stop the antibodies that are damaging the nerves.

Answer: B. Rationale: Plasmapheresis and immunoglobin therapies are treatment options available for GBS, BUT they are only really effective when given within 2 weeks from the onset of symptoms (not 4 weeks).

In autonomic dysreflexia, the nurse would expect what finding below the site of the spinal cord injury? A. Flushed lower body B. Pale and cool lower extremities C. Low blood pressure D. Absent reflexes

Answer: B. Rationale: The lower extremities would be cool and pale due to vasconstriction caused by the exaggerated reflex response of the sympathetic nervous system from an irritating stimulus. The sympathetic reflex can NOT be unopposed by the parasympathetic nervous system due to the spinal injury, which is blocking the nerve impulse. The areas found ABOVE the site of injury would be flushed due to vasodilation from parasympathetic stimulation.

A 25 year-old presents to the ER with unexplained paralysis from the hips downward. The patient explains that a few days ago her feet were feeling weird and she had trouble walking and now she is unable to move her lower extremities. The patient reports suffering an illness about 2 weeks ago, but has no other health history. The physician suspects Guillain-Barré Syndrome and orders some diagnostic tests. Which finding below during your assessment requires immediate nursing action? A. The patient reports a headache. B. The patient has a weak cough. C. The patient has absent reflexes in the lower extremities. D. The patient reports paresthesia in the upper extremities.

Answer: B. Rationale: The patient's signs and symptoms in this scenario are typical with Guillain-Barré Syndrome. The syndrome tends to start in the lower extremities (with paresthesia that will progress to paralysis) and migrate upward. The respiratory system can be affected leading to respiratory failure. Therefore, the nurse should assess for any signs and symptoms that the respiratory system may be compromised (ex: weak cough, shortness of breath, dyspnea...patient says it is hard to breath etc.). The nurse should immediately report this to the MD because the patient may need mechanical ventilation. Absent reflexes is common in GBS and paresthesia can extend to the upper extremities as the syndrome progresses. A headache is not common.

A patient with neurogenic shock is experiencing a heart rate of 30 bpm. What medication does the nurse anticipate will be ordered by the physician STAT? A. Adenosine B. Warfarin C. Atropine D. Norepinephrine

Answer: C. Rationale: Atropine will quickly increase the heart rate and block the effects of the parasympathetic system on the body. Remember bradycardia occurs in neurogenic shock because the sympathetic nervous system (which increases the heart rate) loses its ability to stimulate nerves. The sympathetic and parasympathetic systems are, in a way, balancing each other out when it comes to the heart rate. The sympathetic system increases it, while the parasympathetic decreases it. If the sympathetic system isn't working the way it should, it can NOT oppose the parasympathetic system....which will take over and lead to bradycardia.

You're performing a head-to-toe assessment on a patient with a spinal cord injury at T6. The patient is restless, sweaty, and extremely flushed. You assess the patient's blood pressure and heart rate. The patient's blood pressure is 140/98 and heart rate is 52. You look at the patient's chart and find that their baseline blood pressure is 106/76 and heart rate is 72. What action should the nurse take FIRST? A. Reassess the patient's blood pressure. B. Check the patient's blood glucose. C. Position the patient at 90 degrees and lower the legs. D. Provide cooling blankets for the patient.

Answer: C. Rationale: Based on the patient findings and how the patient has a spinal cord injury at T6, they are experiencing autonomic dysreflexia. Patients with this condition may have a blood pressure that is 20-40 mmHg higher than their baseline and may experience bradycardia (heart rate less than 60). The FIRST action the nurse should take when AD is suspected is to position the patient at 90 degree (high Fowler's) and lower the legs. This will allow gravity to cause the blood to pool in the lower extremities and help decrease the blood pressure. Then the nurse should try to find the cause of the autonomic dysreflexia, which could be a full bladder, impacted bowel, or skin break down.

You're providing care to a patient experiencing neurogenic shock due to an injury at T4. As the nurse, you know which of the following is a patient safety priority? A. Keeping the head of the bed greater than 45 degrees at all times. B. Repositioning the patient every thirty minutes. C. Keeping the patient's spine immobilized. D. Avoiding log-rolling the patient during transport.

Answer: C. Rationale: It is very important when a patient has a spinal cord injury to keep the spine protected. The nurse wants to prevent further damage or perfusion issues to the spinal cord. Therefore, the patient's spine should be immobilized. Example: usage of cervical collar, log-rolling, usage of a backboard.

You're about to send a patient for a lumbar puncture to help rule out Guillain-Barré Syndrome. Before sending the patient you will have the patient? A. Clean the back with antiseptic B. Drink contrast dye C. Void D. Wash their hair

Answer: C. Rationale: The patient will need to void and empty the bladder before going for a LP. This will help decrease the chances of the bladder becoming punctured during the procedure.

Your patient, who has a spinal cord injury at T3, states they are experiencing a throbbing headache. What is your NEXT nursing action? A. Perform a bladder scan B. Perform a rectal digital examination C. Assess the patient's blood pressure D. Administer a PRN medication to alleviate pain and provide a dark, calm environment.

Answer: C. Rationale: This is the nurse's NEXT action. The patient is at risk for developing autonomic dysreflexia because of their spinal cord injury at T3 (remember patients who have a SCI at T6 or higher are at MOST risk). If a patient with this type of injury states they have a headache, the nurse should NEXT assess the patient's blood pressure. If it is elevated, the nurse would take measures to check the bladder (a bladder issue is the most common cause of AD), bowel, and skin for breakdown.

During nursing report you learn that the patient you will be caring for has Guillain-Barré Syndrome. As the nurse you know that this disease tends to present with: A. signs and symptoms that are unilateral and descending that start in the lower extremities B. signs and symptoms that are symmetrical and ascending that start in the upper extremities C. signs and symptoms that are asymmetrical and ascending that start in the upper extremities D. signs and symptoms that are symmetrical and ascending that start in the lower extremities

Answer: D. Rationale: GBS signs and symptoms will most likely start in the lower extremities (ex: feet), be symmetrical, and will gradually spread upward (ascending) to the head. There are various forms of Guillain-Barré Syndrome. Acute inflammatory demyelinating polyradiculoneuropathy (AIDP) is the most common type in the U.S. and this is how this syndrome tends to present.

A 42-year-old male patient is admitted with a spinal cord injury. The patient is experiencing severe hypotension and bradycardia. The patient is diagnosed with neurogenic shock. Why is hypotension occurring in this patient with neurogenic shock? A. The patient has an increased systemic vascular resistance. This increases preload and decreases afterload, which will cause severe hypotension. B. The patient's autonomic nervous system has lost the ability to regulate the diameter of the blood vessels and vasodilation is occurring. C. The patient's parasympathetic nervous system is being unopposed by the sympathetic nervous system, which leads to severe hypotension. D. The increase in capillary permeability has depleted the fluid volume in the intravascular system, which has led to severe hypotension.

The answer is B. Rationale: The sympathetic nervous system (which is a division of the autonomic nervous system) is unable to stimulate the nerves that regulate the diameter of the blood vessels (there's a loss of vasomotor tone). So, now the vessels are relaxed and this causes massive vasodilation. Systemic vascular resistance will decrease and hypotension will occur.

You're teaching a group of nursing students about Guillain-Barré Syndrome and how it can affect the autonomic nervous system. Which signs and symptoms verbalized by the students demonstrate they understood the autonomic involvement of this syndrome? Select all that apply: A. Altered body temperature regulation B. Inability to move facial muscles C. Cardiac dysrhythmias D. Orthostatic hypotension E. Bladder distension

The answers are A, C, D, and E. Rationale: All these are some signs and symptoms that can present in severe cases of GBS when the autonomic nervous system is involved.

In neurogenic shock, a patient will experience a decrease in tissue perfusion. This deprives the cells of oxygen that make up the tissues and organs. Select all the mechanisms, in regards to pathophysiology, of why this is occurring: A. Loss of vasomotor tone B. Increase systemic vascular resistance C. Decrease in cardiac preload D. Increase in cardiac afterload E. Decrease in venous blood return to the heart F. Venous blood pooling in the extremities

The answers are A, C, E, and F. Rationale: Massive vasodilation is occurring in the body and this is due to the loss of vasomotor tone (remember the sympathetic nervous system loses its ability to stimulate nerves that regular the diameter of vessels....so vessels are relaxed). This will DECREASE (NOT increase) systemic vascular resistance (which will decrease cardiac afterload) and the blood pressure will fall. Furthermore, there is pooling of venous blood in the extremities because there isn't any pressure to push it back to the heart. This will cause a decrease in venous blood return to the heart. When this occurs it will decrease cardiac preload (the amount the ventricle stretch at the end of diastole). All of this together will decrease the amount of blood the heart can pump per minute....hence the cardiac output and shock will occur.

Which statements are TRUE about autonomic dysreflexia? Select all that apply: A. "Autonomic dysreflexia is an exaggerated reflex response by the parasympathetic nervous system that results in severe hypertension due to a spinal cord injury." B. "Autonomic dysreflexia causes a slow heart rate and severe hypertension." C. "Autonomic dysreflexia is less likely to occur in a patient who has experienced a lumbar injury." D. "The first-line of treatment for autonomic dysreflexia is an antihypertensive medication."

The answers are B and C. Rationale: Option A is false, it should say: Autonomic dysreflexia is an exaggerated reflex response by the SYMPATHETIC (NOT parasympathetic) nervous system that results in severe hypertension due to a spinal cord injury. Option B is false because medications are used only if the blood pressure is not decreasing or the cause cannot be determined.

You're providing an in-service to a group of new nurse graduates on the causes of autonomic dysreflexia. Select all the most common causes you will discuss during the in-service: A. Hypoglycemia B. Distended bladder C. Sacral pressure injury D. Fecal impaction E. Urinary tract infection

The answers are B, C, D, and E. Rationale: Anything that can cause an irritating stimulus below the site of the spinal injury (T6 or higher) can lead to autonomic dysreflexia, which causes an exaggerated sympathetic reflex response and the parasympathetic system is unable to oppose it. This will lead to severe hypertension. The most common cause of AD is a bladder issue (full/distended bladder, urinary tract infection etc). Other common causes are due to a bowel issue like fecal impaction or skin break down (pressure injury/ulcer, cut, infection etc.).

You're assessing a patient's health history for risk factors associated with developing Guillain-Barré Syndrome. Select all the risk factors below: A. Recent upper respiratory infection B. Patient's age: 3 years old C. Positive stool culture Campylobacter Jejuni D. Hyperthermia E. Epstein-Barr F. Diabetes G. Myasthenia Gravis

The answers are: A, C, and E. Rationale: Risk factors for developing Guillain-Barré Syndrome include: experiencing upper respiratory infection, GI infection (especially from Campylobacter Jejuni), Epstein-Barr infection, HIV/AIDS, vaccination (flu or swine flu) etc.

A patient with Guillain-Barré Syndrome has a feeding tube for nutrition. Before starting the scheduled feeding, it is essential the nurse? Select all that apply: A. Assesses for bowel sounds B. Keeps the head of bed less than 30' degrees C. Checks for gastric residual D. Weighs the patient

The answers: A and C. Rationale: Some patients who experience GBS will need a feeding tube because they are no longer able to swallow safely due to paralysis of the cranial nerves that help with swallowing. GBS can lead to a decrease in gastric motility and paralytic ileus. Therefore, before starting a scheduled feeding the nurse should always assess for bowel sounds and check gastric residual.