ATI- Spine/Stroke

A home health nurse is caring for a client who is quadriplegic following a spinal cord injury and who is adjusting to the home environment. Which of the following client statements indicate the client is adapting? "My wife tries to get me to go to the grocery store, but I don't like to go out much." "I am using the modified feeding utensils at every meal. I still spill, but I'm getting better." "My greatest pleasure each day is having a few beers every day." "I have all the equipment to take a shower, but I prefer a bed bath, because it is easier."

"I am using the modified feeding utensils at every meal. I still spill, but I'm getting better." The client is adapting to the physical condition and displays goal setting.

A nurse is teaching a client who has multiple sclerosis and a new prescription for dantrolene. Which of the following statements by the client indicates an understanding of the teaching? "I need to apply a sunscreen when I go outside." "I can take an over-the-counter antihistamine for allergies when I'm taking this drug." "I should take this medication when my spasms are bad." "My muscle strength should improve a lot in 2 to 3 days."

"I need to apply a sunscreen when I go outside." This medication can cause photosensitivity; therefore, the client should protect her skin by wearing a hat and using sunscreen while in sunlight.

A nurse is presenting discharge instructions to a client who has multiple sclerosis (MS). The client reports symptoms of diplopia, dysmetria, and sensory change. Which of the following nursing statements are appropriate? "Wear an eye patch on the right eye at all times." "Plan to relax in a hot tub spa each day." "Engage in a vigorous exercise program." "Implement a schedule to include periods of rest."

"Implement a schedule to include periods of rest." The nurse should assist the client in developing a schedule that includes periods of exercise followed by periods of rest to maintain muscle strength and coordination.

A nurse is teaching the family of a client who is receiving treatment for a spinal cord injury with a halo fixation device. Which of the following statements should the nurse make? "Turn the screws on the device once each day." "The purpose of this device is to immobilize the cervical spine." "Apply talcum powder under the vest to limit friction." "The purpose of this device is to allow for neck movement during the healing process."

"The purpose of this device is to immobilize the cervical spine." A client who has an injury to the cervical spine can have a halo fixation device to provide immobilization of the head and neck for a period of 8 to 12 weeks.

A nurse is caring for a client who has right-sided paralysis from a stroke. Which of the following interventions should the nurse implement to prevent footdrop?- Place sandbags to maintain right plantar flexion.- Position soft pillows against the bottom of the feet.- Apply a protective boot to the right ankle.- Splint the right lower extremity to maintain proper alignment.

- Apply a protective boot to the right ankle. The nurse should apply padded splints or protective boots to the foot at a right angle to the leg to prevent footdrop.

A nurse is caring for a client who has had a stroke involving the right hemisphere. Which of the following alterations in function should the nurse expect?- Difficulty reading- Inability to recognize his family members- Right hemiparesis- Aphasia

- Inability to recognize his family members The right hemisphere is involved with visual and spatial awareness. A client who is unable to recognize faces would have involvement with the right hemisphere.

a nurse is performing a home safety assessment for a client who has experienced a stroke. which of the findings are a safety hazard -dim lightening installed throughout the house - the hot water is set to 130 -medications are stored in a clear bag -grab bars are installed in the bathroom -area rugs are placed in the living room

-dim lightening installed throughout the house - the hot water is set to 130 -medications are stored in a clear bag -area rugs are placed in the living room

a nurse is performing passive range of motion who had a stroke. the nurse should identify that passive range of motion is performed to increased which of the following muscle strength joint flexibility muscle mass bone density

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A nurse is teaching a client who has multiple sclerosis about starting therapy with baclofen (Lioresal). Which of the following instructions should the nurse include? - do not take antihistamines with this medications -take the medications on an empty stomach -stop taking the medication immediately for a headache -expect to develop diarrhea

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a nurse is caring for a client who has urinary leakage due to nerve damage following a spinal cord injury. The nurse should identify that the client is experiencing which of the following types of urinary incontinence? -stress incontinence -overflow incontinence -reflex incontinence -urge incontience

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An older adult client in a long term care facility had a stroke 4 weeks ago and has been unable to move independently since that time period. The nurse caring for her should observe for which other following findings that indicates a complication of immobility

A reddened area over the sacrum

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? Ability to achieve independent transfer from bed to wheelchair Independent control of bowel and bladder function Use of a wheelchair with a chin or mouth stick Ability to self-feed with the use of adaptive equipment

Ability to self-feed with the use of adaptive equipment A client who has a spinal cord transection at the level of the fifth cervical vertebrae should have full neck, partial shoulder, back, biceps, and gross elbow movements. A realistic rehabilitation goal for the client is the ability to feed himself with the use of adaptive equipment.

A nurse on the intensive care unit is caring for a client who has severe traumatic brain injury and a cerebral perfusion pressure (CPP) of 59 mm Hg. Which of the following actions should the nurse take? Provide warming measures for the client. Hyperextend the client's neck. Flex the client's hip. Adjust the client's head of bed.

Adjust the client's head of bed. The nurse should adjust the client's head of bed to keep CPP greater than 70 mm Hg.

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? Apply downward pressure while the client shrugs his shoulders upward. Apply resistance while the client lifts his legs from the bed. Ask the client to grasp an object and form a fist. Apply resistance while the client flexes his arms.

Apply downward pressure while the client shrugs his shoulders upward.This assessment monitors the motor function of C4 to C5.

A nurse is caring for a client who has an intracranial pressure (ICP) reading of 40 mm Hg. Which of the following findings should the nurse identify as a late sign of ICP? (Select all that apply.) Confusion Bradycardia Hypotension Nonreactive dilated pupils Slurred speech

Confusion is incorrect. A change in the level of consciousness is an early sign of neurologic status. This is often manifested as restlessness, irritability, and confusion. Bradycardia is correct. Bradycardia is one of three findings of Cushing's triad, which is a late sign of increased intracranial pressure. A client who has hypovolemic shock is more likely to have tachycardia. Hypotension is incorrect. Severe hypertension is one of three findings of Cushing's triad, which is a late sign of increased intracranial pressure. A client who has hypovolemic shock is more likely to have hypotension. Nonreactive dilated pupils is correct.Increased intracranial pressure can lead to nonreactive dilated pupils or constricted nonreactive pupils. Slurred speech is incorrect. Slowed speech can be an early sign of increased intracranial pressure. Late manifestations include stupor, progressing to coma, and abnormal motor responses, including decorticate and decerebrate posturing.

A nurse is caring for a client who has sustained a traumatic brain injury. The nurse should monitor the client for which of the following manifestations of increased intracranial pressure? Decreased level of consciousness Tachypnea Bilateral weakness of extremities Hypotension

Decreased level of consciousness As intracranial pressure increases, cerebral perfusion, and therefore level of consciousness, decrease. Other manifestations include severe headache, irritability, and pupils that are slow to react or are unreactive to light.

A nurse is planning care for a female client who has a T4 spinal cord injury and is at risk for acquiring urinary tract infections. Which of the following actions should the nurse include in the client's plan of care? Cleanse the perineum from back to front. Obtain a prescription for an indwelling urinary catheter. Encourage fluid intake at and between meals. Offer the client the bedpan every 2 hr.

Encourage fluid intake at and between meals. Increased fluid intake dilutes the urine, reduces stasis, and greatly reduces the urinary bacterial count. Consequently, the risk of nosocomial (hospital-acquired) UTI is reduced, even for a client who has a spinal cord injury.

A nurse is instructing a client's family members about feeding safety for a client who has dysphagia following a stroke. Which of the following instructions should the nurse include?

Encourage the client to take small bites.

A rehabilitation nurse is caring for a client who has had a spinal cord injury that resulted in paraplegia. After a week on the unit, the nurse notes that the client is withdrawn and increasingly resistant to rehabilitative efforts by the staff. Which of the following actions should the nurse take? Inform the client that privileges are related to participation in therapy. Limit visiting hours until the client begins to participate in therapy. Allow the client to control the timing and frequency of the therapy. Establish a plan of care with the client that sets attainable goals

Establish a plan of care with the client that sets attainable goals. The nurse should develop a plan of care for this client with mutually set goals. This action invests the client in the rehabilitation process, which encourages feelings of ownership for it, and sees the goals as more attainable.

A nurse is monitoring a client who has a leaking cerebral aneurysm. Which of the following manifestations should indicate to the nurse the client is experiencing an increase in intracranial pressure (ICP)? (Select all that apply.) Headache Neck pain and stiffness Slurred speech Pupillary changes Disorientation

Headache is correct. A client who has increasing ICP might manifest a headache. Neck pain and stiffness is incorrect.Neck pain and stiffness are not manifestations of increasing ICP. Slurred speech is correct. A client who has increasing ICP might manifest slurred speech. Pupillary changes is correct. A client who has increasing ICP might manifest pupillary changes. Disorientation is correct. A client who has increasing ICP might display disorientation or confusion.

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

Hypotension is correct. Lack of sympathetic input can cause a decrease in blood pressure. The nurse should maintain the client's SBP at 90 mm Hg or above to adequately perfuse the spinal cord. Polyuria is incorrect. The nurse should check the client for bladder distention and inability to urinate due to ineffective function of the bladder muscles. Hyperthermia is incorrect. The nurse should monitor the client for hypothermia caused by a lack of lack of sympathetic input. Absence of bowel sounds is correct.Spinal shock leads to decreased peristalsis, which could cause the client to develop a paralytic ileus. Weakened gag reflex is correct. The nurse should monitor the client for difficulty swallowing, or coughing and drooling noted with oral intake.

A nurse is caring for a client who had a stroke involving the left cerebral hemisphere. The nurse should monitor for which of the following findings?

Impaired sense of humor

A nurse is caring for a client who has aphasia following a stroke. A family member asks the nurse how she should communicate with the client. Which of the following responses by the nurse is appropriate?

Incorporate nonverbal cues in the conversation.

A nurse is caring for a client who has had a hemorrhagic stroke following a ruptured cerebral aneurysm. Which of the following manifestations should the nurse excpect?

Manifestations preceded by a severe headache.

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.) Massage over erythematous bony prominences. Implement turning schedule every 4 hr. Use pillows to keep heels off the bed surface. Keep the client's skin dry with powder. Minimize skin exposure to moisture

Massage over erythematous bony prominences is incorrect. The nurse should avoid massaging bony prominences, since it may cause further skin break down. Implement turning schedule every 4 hr is incorrect. The nurse should implement a 2 hr turning schedule to prevent skin breakdown. Use pillows to keep heels off the bed surface is correct. The nurse should keep the heels off the bed to prevent skin breakdown on the client's heels. Keep the client's skin dry with powder is incorrect. The nurse should apply lotion and avoid applying powder to the skin, which may cause skin breakdown. Minimize skin exposure to moisture is correct. The nurse should minimize skin exposure to moisture to prevent skin breakdown.

a nurse is teaching the partner of a client who had a stroke about dysphagia. Which of the following statements by the clients partners should indicate to the nurse that the teaching was effective

My partner should tilt their head forward when shallowing

A nurse is caring for a client who has had a spinal cord injury at the level of the T2-T3 vertebrae. When planning care, the nurse should anticipate which of the following types of disability? Paresthesia Hemiplegia Quadriplegia Paraplegia

Paraplegia Paraplegia, or paralysis of both legs, is seen after a spinal cord injury below T1.

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? Administer a nitrate antihypertensive. Assess the client for bladder distention. Place the client in a high-Fowler's position. Obtain the client's heart rate.

Place the client in a high-Fowler's position. The client who is experiencing autonomic dysreflexia is at risk for a cerebrovascular accident resulting from severe hypertension. According to the safety and risk reduction priority setting framework, the nurse's initial action should be to place the client in a high-Fowler's position to assist in providing immediate reduction in blood pressure and intracranial pressure.

A nurse is caring for a client who has a spinal cord injury and suspects the client is developing autonomic dysreflexia. Which of the following actions should the nurse take first? Check the client for a fecal impaction. Examine the client for areas of skin breakdown. Check the client's bladder for distention. Place the client in a sitting position

Place the client in a sitting position. The nurse should use the least invasive intervention first. Therefore, the nurse should place the client in a sitting position to decrease the manifestation of hypertension.

A nurse is caring for a client who had a stroke involving the right cerebral hemisphere. The nurse should monitor for which of the following findings?

Poor impulse control

A nurse is caring for a client who has a right-sided stroke and is exhibiting homonymous hemianopsia when eating. Which of the following actions should the nurse take?

Remind the client to look for food on the left side of the tray.

A nurse is caring for a client who has a traumatic brain injury. Which of the following findings should the nurse identify as an indication of increased intracranial pressure (ICP)? Tachycardia Amnesia Hypotension Restlessness

Restlessness Increased intracranial pressure is a condition in which the pressure of the cerebrospinal fluid or brain matter within the skull exceeds the upper limits for normal. Signs of increasing ICP include restlessness, irritability and confusion along with a change in level of consciousness, or a change in speech pattern.

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? The client states having a severe headache. The client's bladder becomes distended. The client's blood pressure becomes elevated. The client states having nasal congestion.

The client's bladder becomes distended. Autonomic dysreflexia (sometimes called hyperreflexia) can occur in clients with a spinal cord injury at or above the T6 level. Autonomic dysreflexia happens when there is an irritation, pain, or stimulus to the nervous system below the level of injury. There are many kinds of stimulation that can precipitate autonomic dysreflexia. For example, catheter changes, a distended bladder or bowel, enemas, and sudden position changes. Manifestations include elevated blood pressure, severe headache, and flushed face

A nurse is caring for a client who has increased intracranial pressure (ICP) following a closed-head injury. Which of the following actions should the nurse take? Instruct the client to cough and deep breathe. Place the client in a supine position. Place a warming blanket on the client. Use log rolling to reposition the client

Use log rolling to reposition the client. Treatment of increased ICP focuses on decreasing the pressure. An important intervention includes positioning the client in a neutral position and avoiding flexion of the neck and hips. In order to avoid hip flexion, the client should be log rolled when repositioned.

A nurse is admitting a young adult client who has suspected bacterial meningitis. The nurse should closely monitor the client for increased intracranial pressure (ICP) as indicated by which of the following findings? -Nuchal rigidity -Pupils reactive to light -Widened pulse pressure -Elevated temperature

Widened pulse pressure A widened pulse pressure is a manifestation of increased ICP. Other manifestations include bradycardia, vomiting, and decreased level of consciousness.

nurse is instructing a client's family members about feeding safety for a client who has dysphagia following a stroke. the nurse should monitor the client for what complication

aspiration

a nurse is discussing a clients need at an interdisciplinary team conference. The client had a stroke and requires inpatient rehab incorporated into their plan of care. which of the nursing competencies is the nurse demonstrating

case manager

A nurse is caring for a client who has a mild traumatic brain injury (TBI). Which of the following manifestations should the nurse immediately report to the provider? A change in the Glasgow Coma Scale score from 13 to 11 Diplopia A drop in heart rate from 76 to 70/min Ataxia

change in the Glasgow Coma Scale score from 13 to 11 In a client who has mild TBI, a decrease of 2 points on the Glasgow Coma Scale indicates a decrease in level of consciousness and that the client is risk of a deteriorating neurologic status. Therefore, this finding is the priority to report to the provider.

a nurse is giving change of shift report using SBAR to the oncoming nurse on a client who has a traumatic brain injury. Which of the following information should the nurse include in the background segment of SBAR

code status

A nurse is teaching about risk factors of developing a stroke with a group of older adult clients. Which of the following nonmodifiable risk factors should the nurse include in the teaching?

genetics

a nurse is assisting a client who has spinal injury with bathing. which of the following actions should the nurse take

give the client a long handled sponge

a nurse is caring for a client who recently had a stroke. the client requires assistance with strengthening the affected side. Which of the following referrals should eh nurse anticipate the provider to make

physical therapist

a nurse suspects that a client admitted for treatment of bacterial meningitis is experiencing increased intracranial pressure. Which of the following assessment findings by the nurse supports this suspicion photophobia nuchal rigidity positive kernigs restlessness

positive kernigs

The nurse is planning care for a client who had a traumatic brain injury and is emerging restlessly from a coma. Which of the following interventions should the nurse include in the plan

reduce stimuli