Unit 4: Peripheral Nerve and Spinal Cord Problems

A nurse is assessing a client who has suspected diagnosis of Guillain-Barre syndrome (GBS). Which of the following questions should the nurse ask the client? a. "Do you have a history of chronic alcohol abuse?" b. "Have you had a recent influenza infection?" c. "Have you traveled overseas recently?" d. "Are you taking a multivitamin?"

b. "Have you had a recent influenza infection?"

A nurse is caring for a client who has dementia. The client is agitated and is having difficulty staying in his chair. Which of the following actions should the nurse take first? a. Apply a vest restraint on the client b. Place the client in bed with the two side rails raised c. Place a seat alarm in the client's chair d. Administer lorazepam to the client

c. Place a seat alarm in the client's chair

During rehabilitation, a patient with a 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

a. L1-2

A priority goal of treatment for the patient with Alzheimer's disease is to a. maintain patient safety b. maintain or increase body weight c. return to a higher level of self-care d. enhance functional ability over time

a. maintain patient safety

The nurse has completed discharge instructions for a client with application of a halo device who sustained a cervical spinal cord injury. Which statement indicates that the client needs further clarification of the instructions? a. i will use a straw for drinking b. i will drive only during the daytime c. i will be careful because the device alters balance d. i will wash the skin daily under the lamb's wool liner of the vest

b. i will drive only during the daytime

A nurse on a long-term care unit is creating a plan of care for a client who has Alzheimer's disease. Which of the following interventions should the nurse include in the plan? a. Rotate assignment of daily caregivers b. Provide an activity schedule that changes from day to day c. Limit time for the client to perform activities d. Talk the client through tasks one step at a time

d. Talk the client through tasks one step at a time

Which patient is most at risk for developing delirium? a. a 50 yr old woman with cholecystitis b. a 19 yr old man with a fractured femur c. a 42 yr old woman having an elective total hysterectomy d. a 78 yr old man admitted to the medical unit with complications of heart failure

d. a 78 yr old man admitted to the medical unit with complications of heart failure

The nurse is admitting a client with GBS to the nursing unit. The client has complaints of inability to move both legs and reports a tingling sensation above the waistline. Knowing the complications of the disorder, the nurse should bring which most essential items into the client's room? a. nebulizer and pulse oximeter b. BP cuff and flashlight c. nasal cannula and incentive spirometer d. electrocardiographic monitoring electrodes and intubation tray

d. electrocardiographic monitoring electrodes and intubation tray

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

b. hypotension

During nursing report, you learn that the patient you will be caring for has GBS. 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

d. signs and symptoms that are symmetrical and ascending that start in the lower extremities

A nurse is assessing a client who has a spinal cord injury. Which of the following actions should the nurse take to monitor C4 function? a. Apply downward pressure while the client shrugs his shoulders upward b. Apply resistance while the client lifts his legs from the bed c. Ask the client to grasp an object and form a fist d. Apply resistance while the client flexes his arms

a. Apply downward pressure while the client shrugs his shoulders upward

A nurse is teaching the family of a client who has Alzheimer's disease about donepezil. Which of the following information should the nurse include in the teaching? a. "Syncope episodes may occur when taking this medication." b. "This medication may cause tachycardia." c. "You should administer the medication each morning." d. "You will need to monitor for constipation."

a. "Syncope episodes may occur when taking this medication."

A nurse is caring for a client who has late-stage Alzheimer's disease and is hospitalized for treatment of pneumonia. During the night shift, the client is found climbing into the bed of another client who becomes upset and frightened. Which of the following actions should the nurse take? a. Assist the client to the correct room b. Place the client in restraints c. Reorient the client to time and place d. Move the client to a room at the end of the hall

a. Assist the client to the correct room

A nurse in the ER is monitoring a client who has a cervical spinal injury from a fall. The nurse should monitor the client for which of the following complications? (Select all that apply) a. Hypotension b. Polyuria c. Hyperthermia d. Absence of bowel sounds e. Weakened gag reflex

a. Hypotension d. Absence of bowel sounds e. Weakened gag reflex

A nurse is assessing a client who has Bell's palsy. Which of the following findings should the nurse expect? (Select all that apply) a. Muscle distortion b. Pain behind the ear c. Hearing loss d. Facial twitching e. Impaired taste

a. Muscle distortion b. Pain behind the ear e. Impaired taste

A nurse is caring for a client who experienced a cervical spine injury 3 months ago. The nurse should plan to implement which of the following types of bladder management methods? a. condom catheter b. intermittent urinary catheterization c. Crede's method d. indwelling urinary catheter

a. condom catheter

A nurse assesses a client who has GBS. Which of the following findings would be expected for this client? (select all that apply) a. diplopia b. paresthesia c. thrombocytopenia d. rebound tenderness e. hyperactive reflexes

a. diplopia b. paresthesia

A nurse is caring for a client who has AD. A family member of the client asks the nurse about risk factors for the disease. Which of the following should be included in the nurse's response? (select all that apply) a. exposure to metal waste products b. long-term estrogen therapy c. sustained use of vitamin E d. previous head injury e. history of herpes infection

a. exposure to metal waste products d. previous head injury e. history of herpes infection

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 RR and depth c. lightly palpate the affected side of the face for edema d. test for temperature and sensation perception of the face e. ask the patient to describe factors that initiate an episode

a. inspect all aspects of the mouth and teeth d. test for temperature and sensation perception of the face e. ask the patient to describe factors that initiate an episode

A client with a spinal cord injury is prone to experiencing autonomic dysreflexia. The nurse should include which measures in the plan of care to minimize the risk of occurrence? (select all that apply) a. keep the linens wrinkle-free under the client b. preventing unnecessary pressure on the lower limbs c. limiting bladder catheterization to once every 12 hours d. turning and repositioning the client at least every 2 hours e. ensuring that the client has a bowel movement at least once a week

a. keep the linens wrinkle-free under the client b. preventing unnecessary pressure on the lower limbs d. turning and repositioning the client at least every 2 hours

A nurse is planning care for a client who has a spinal cord injury involving a T-12 fracture 1 week ago. The client has no muscle control of the lower limbs, bowel, or bladder. Which of the following should be the nurse's priority? a. prevention of further damage to the spinal cord b. prevention of contractures of the lower extremities c. prevention of skin breakdown of areas that lack sensation d. prevention of postural hypotension when placing the client in a wheelchair

a. prevention of further damage to the spinal cord

A nurse is making a home visit to a client who is in the late stage of Alzheimer's disease. The client's partner states that the client is often disoriented to time and place, is unsteady, and has a history of wandering. Which of the following safety measures should the nurse review with the partner? (select all that apply) a. remove floor rugs b. have door locks that can be easily opened c. provide increased lighting in stairwells d. install handrails in the bathroom e. place the mattress on the floor

a. remove floor rugs c. provide increased lighting in stairwells d. install handrails in the bathroom e. place the mattress on the floor

A nurse is caring for a group of older adult clients. Which of the following manifestations indicates one of the clients is experiencing delirium? a. A client wants to know the current time while there is a clock on the wall b. A client attempts to climb out of bed and repeatedly states she must get home c. A client requests extra blankets when the thermostat in the room indicates 78F d. A client refuses to get out of bed and is not motivated to attend to daily hygiene

b. A client attempts to climb out of bed and repeatedly states she must get home

A nurse is teaching a group of newly licensed nurses about the progressive nature of Alzheimer's disease. Which of the following should the nurse include in the teaching as manifestations seen on the moderate stage of Alzheimer's disease? (Select all that apply) a. Inability to find commonly used items b. Inability to perform common tasks c. Difficulty with talking or reading d. Difficulty remembering how to swallow e. Inability to recognize family members

b. Inability to perform common tasks c. Difficulty with talking or reading

A nurse is caring for a client who has a T-4 spinal cord injury. Which of the following client findings should the nurse identify as an indication the client is at risk for experiencing autonomic dysreflexia? a. The client states having a severe headache b. The client's bladder becomes distended c. The client's blood pressure becomes elevated d. The client states having nasal congestion

b. The client's bladder becomes distended

When the nurse is planning care for a hospitalized patient who is experiencing an acute episode of trigeminal neuralgia, an appropriate action to include is a. teach facial and jaw relaxation techniques b. assess intake and output and dietary intake c. apply ice packs for no more than 20 minutes d. spend time at the bedside talking with the patient

b. assess intake and output and dietary intake

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, light touch

b. back pain that worsens with activity

________ is due to the loss of ANS vasomotor tone caused by injury and is characterized by hypotension and bradycardia. a. spinal shock b. neurogenic shock c. hypoxia d. autonomic dysreflexia

b. neurogenic shock

A nurse is caring for a client who has AD and falls frequently. Which of the following actions should the nurse take to keep the client safe? a. keep the call light near the client b. place the client in a room close to the nurse's station c. encourage the client to ask for assistance d. remind the client to walk with someone for support

b. place the client in a room close to the nurse's station

A nurse is caring for a client who has a spinal cord injury who reports a severe headache and is sweating profusely. Vital signs include BP 220/110 and apical HR 54/min. Which of the following actions should the nurse take first? a. examine skin for irritation or pressure b. sit the client upright in bed c. check the urinary catheter for blockage d. administer antihypertensive medication

b. sit the client upright in bed

Which statement(s) accurately describe(s) mild cognitive impairment? (select all that apply) a. cannot be detected by screening tests b. the person may appear normal to the casual observer c. family members may see changes in the patient's abilities d. problems that the person is experiencing interfere with daily activities e. the person is usually aware that there is a problem with his or her memory

b. the person may appear normal to the casual observer c. family members may see changes in the patient's abilities e. the person is usually aware that there is a problem with his or her memory

A nurse is teaching the family of an older adult client who has a new diagnosis of dementia. Which of the following statements should the nurse include in the teaching? a. "Dementia is characterized by a sudden onset of confusion." b. "An altered level of consciousness is associated with dementia?" c. "The signs of dementia are progressive and irreversible." d. "Dementia can be triggered by a high fever or dehydration."

c. "The signs of dementia are progressive and irreversible."

A nurse is caring for a confused client who has Alzheimer's disease. Which of the following actions should the nurse take? a. Turn the television on at all times b. Hang abstract pictures on the walls c. Keep familiar personal items at the bedside d. Encourage bright glaring lighting in the room

c. Keep familiar personal items at the bedside

A nurse is caring for an older adult client who has dementia and handles anxiety by confabulating. The nurse should recognize confabulating when the client... a. Displays compulsive and ritualistic behaviors b. Reminisces about the past c. Makes up stories when he is unable to remember actual events d. Refuses to leave home to see provider

c. Makes up stories when he is unable to remember actual events

A nurse is caring for a client who has quadriplegia from a spinal cord injury and reports having a severe headache. The nurse obtains a blood pressure reading of 210/108 mm Hg and suspects the client is experiencing autonomic dysreflexia. Which of the following actions should the nurse take first? a. Administer a nitrate antihypertensive b. Assess the client for bladder distention c. Place the client in a high-Fowler's position d. Obtain the client's HR

c. Place the client in a high-Fowler's position

A nurse in a long-term care facility is caring for a client who has Alzheimer's disease. Which of the following actions should the nurse include in the plan of care? a. Post a written schedule of daily activities b. Use an overhead loudspeaker to announce events c. Provide a consistent daily routine d. Allow the client to choose free-time activities

c. Provide a consistent daily routine

A nurse is developing a plan of care to prevent skin breakdown for a client with a spinal cord injury and paralysis. Which of the following nursing actions are appropriate? (Select all that apply) a. Massage over erythematous bony prominences b. Implement turning schedule every 4 hours c. Use pillows to keep the heels off the bed surface d. Keep the client's skin dry with powder e. Minimize skin exposure to moisture

c. Use pillows to keep the heels off the bed surface e. Minimize skin exposure to moisture

Vascular dementia is associated with a. transient ischemic attacks b. bacterial or viral infection of neuronal tissue c. cognitive changes secondary to cerebral ischemia d. abrupt changes in cognitive function that are irreversible

c. cognitive changes secondary to cerebral ischemia

The nurse is evaluating the neurological signs of a client in spinal shock following spinal cord injury. Which observation indicates that spinal shock persists? a. hyperreflexia b. positive reflexes c. flaccid paralysis d. reflex emptying of the bladder

c. flaccid paralysis

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

c. flexion-rotation

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 nurses first priority is to a. call the healthcare provider b. check the patient's temperature c. measure the patient's BP d. elevate the HOB to 90 degrees

c. measure the patient's BP

Dementia with Lewy bodies (DLB) is characterized by a. remissions and exacerbations over many years b. memory impairment, muscle jerks, and blindness c. parkinsonian symptoms, including muscle rigidity d. increased ICP from decreased CSF drainage

c. parkinsonian symptoms, including muscle rigidity

A 71-year-old patient with AD who is being admitted to a long-term care facility has had several episodes of wandering away from home. Which action will the nurse include in the plan of care? a. reorient the patient several times daily b. have the family bring in familiar items c. place the patient in a safe environment close to the nurse's station d. ask the patient why the wandering episodes have occurred

c. place the patient in a safe environment close to the nurse's station

A client with GBS has ascending paralysis and is intubated and receiving mechanical ventilation. Which strategy should the nurse incorporate in the plan of care to help the client cope with this illness? a. giving the client full control over care decisions and restricting visitors b. providing positive feedback and encouraging active range of motion c. providing information, giving positive feedback, and encouraging relaxation d. providing IV sedatives, reducing distractions, and limiting visitors

c. providing information, giving positive feedback, and encouraging relaxation

A nurse is providing teaching to the partner of a client who has AD and has a new prescription for donepezil. Which of the following statements by the partner indicates the teaching is effective? a. this medication should increase my husbands appetite b. this medication should help mu husband sleep better c. this medication should help my husbands daily function d. this medication should increase my husbands energy level

c. this medication should help my husbands daily function

A nurse is developing a plan of care for a client who has a spinal fracture and complete spinal cord transection at the level of C5. Which of the following rehabilitation goals should the nurse add to the client's plan of care? a. Ability to achieve independent transfer from bed to wheelchair b. Independent control of bowel and bladder function c. Use of a wheelchair with a chin or mouth stick d. Ability to self-feed with the use of adaptive equipment

d. Ability to self-feed with the use of adaptive equipment

A community health nurse is providing teaching to the family of a client who has primary dementia. Which of the following manifestations should the nurse tell the family to expect? a. Decreased auditory and visual acuity b. Decreased display of emotions c. Personality traits that are opposite of original traits d. Forgetfulness gradually progressing to disorientation

d. Forgetfulness gradually progressing to disorientation

A home health nurse is planning care for a client who has Alzheimer's disease. The client's partner is her primary caregiver and reports not having enough time to complete his errands. Which of the following referrals should the nurse plan to make? a. Hospice care b. Restorative care c. Mental health care d. Respite care

d. Respite care

The nurse has given suggestions to a client with trigeminal neuralgia about strategies to minimize episodes of pain. The nurse determines that the client needs further teaching if the client makes which statement? a. i will wash my face with cotton pads b. i will have to start chewing on my unaffected side c. i should rinse my mouth if toothbrushing is painful d. i will try to eat my food either very warm or very cold

d. i will try to eat my food either very warm or very cold

A nurse is caring for a client who experienced a cervical spine injury 24 hours ago. Which of the following prescriptions should the nurse clarify with the provider? a. anticoagulant b. plasma expanders c. H2 antagonists d. muscle relaxants

d. muscle relaxants

During routine assessment of a patient with GBS, 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

d. paralysis ascending to the nerves that stimulate the thoracic area

The clinical diagnosis of dementia is based on a. CT or MRS b. brain biopsy c. electroencephalogram d. patient history and cognitive assessment

d. patient history and cognitive assessment

A nurse working in a long-term care facility is planning care for a client who has moderate AD. Which of the following interventions should be included in the plan of care? a. use a gait belt for ambulation b. thicken all liquids c. provide protective undergarments d. reorient the client to self and current events

d. reorient the client to self and current events

A nurse is caring for a client who has a C4 spinal cord injury. The nurse should recognize the client is at greatest risk for which of the following complications? a. neurogenic shock b. paralytic ulcer c. stress ulcer d. respiratory compromise

d. respiratory compromise

The client is admitted to the hospital with a diagnosis of GBS. Which past medical history finding makes the client most at risk for this disease? a. meningitis or encephalitis during the last 5 years b. seizures or trauma to the brain within the last year c. back injury or trauma to the spinal cord during the last 2 years d. respiratory or gastrointestinal infection during the previous month

d. respiratory or gastrointestinal infection during the previous month

Dementia is defined as a a. syndrome that results only in memory loss b. disease associated with abrupt changes in behavior c. disease that is always due to reduced blood flow to the brain d. syndrome characterized by cognitive dysfunction and loss of memory

d. syndrome characterized by cognitive dysfunction and loss of memory