Chapter 61

18. A patient is admitted to the ER with a possible cervical spinal cord injury following a car crash. During the admission of the patient the nurse places the highest priority on .. a. maintaining a patent airway b. assessing the patient for head and other injuries c. maintaining immobilization of the cervical spine. d. assessing the patients motor and sensory function

...A

15. A patient is admitted to the emergency department with a spinal cord injury at level of T2. Which of the following findings is of the most concern to the nurse? a. SpO of 92% b. HR of 42 beats/min c. blood pressure of 88/60 d. loss of motor and sensory function in arms and legs

B. Neurologic shock associated with cord injuries above the level of T6 greatly decrease the effects of the sympathetic nervous system, and Bradycardia and hypotension occur. A heart rate of 42 is not adequate to meet oxygen needs of the body and while low the blood pressure is not at a critical point. The oxygen saturation is satisfactory and the motor sensory loss are expected.

8. In planning community education for prevention of spinal cord injuries, the nurse targets. a. elderly men b. teenage girls c. elementary school-age children d. adolescent and young adult men

D. Spinal cord injuries are highest in young adult men between the ages of 15 and 30 and those who are impulsive or risk takers in daily living. Other risk factors include alcohol and drug abuse as well as participation in sports and occupational exposure to trauma or violence.

3. Surgical intervention is being considered for a patient with trigeminal neuralgia. The nurse recognizes that the procedure that has the least residual effects with positive outcomes is... a. glycerol rhizotomy b. gamma knife radiosurgery c. microvascular decompression d. percutaneous radiofrequency rhizotomy

A. Although percutaneous radiofrequency rhizotomy and microvascular decompression provide the greatest relief of pain ,glycerol rhizotomy causes less sensory loss and fewer sensory aberrations with comparable or better pain relief. Gamma knife radiosurgery provides precise radiation useful for persistent pain after other surgery

23 Urinary function during the acute phase of spinal cord injury is maintained with .... A. an indwelling catheter b. intermittent catheterization C. insertion of a suprapubic catheter d. use of incontinent pads to protect the skin.

A. During the acute phase of spinal cord injury the bladder is hypotonic, causing urinary retention with the risk of reflux into the kidney or rupture of the bladder. An indwelling catheter is used to keep the bladder empty and closely monitor urinary output. Intermittent catheterization or other urinary drainage methods may used in long-term bladder management. Use of in content pads is inappropriate because the bladder fails to empty

28. During the patients process of grieving for the losses resulting from spinal cord injury, the nurse.. A. helps the patient understand that working through the grief will be a lifelong process. b. should assist the patient to move through all of the stages from mourning to acceptance. C. lets the patient know that anger directed at the staff or the family is not a positive coping mechanism d. facilitates the grieving process so that it is completed by the time the patient is discharged from rehabilitation.

A. Working through the grief process is a lifelong process that is triggered by new experiences such as marriage , child rearing, employment or illness which the patient must adjust to throughout life within the context of his or her disability . the goal of recovery is related to adjustment rather than acceptance and many patients do not experience all components of the grief process during the anger phase patients should be allowed outbursts and the nurse should use humor to displace some of the patients anger.

14. Indicate the lowest level of acute spinal cord injury at which the following effects occur. a.GI hypomotility with paralytic ileus and gastric distention. b. loss of all respiratory muscle function c. Respiratory diaphragmatic breathing. d. Decreased response of the sympathetic nervous system.

A. above T5 B. above C4 C. Below C4 D. above T6

5. A patient is admitted to the hospital with Gillian-Barre syndrome. She had weakness in her feet and ankles that has progressed to weakness with numbness and tingling in both legs. During the acute phase of her illness, the nurse recognizes that... a. the most important aspect of care is to monitor the patient's respiratory rate and depth and vital capacity. b. early treatment with corticosteroids can suppress the immune response and prevent ascending nerve damage. c. although voluntary motor neurons are damaged by the inflammatory response, the autonomic nervous system is unaffected by the disease. d. the most serious complication of this condition is ascending demyelination of the peripheral nerves of the lower brainstem and cranial nerves.

A. the most serious complication of Gillian Barre syndrome is respiratory failure and it is essential that respiratory rate, depth and vital capacity are monitored to detect involvement of the nerves that affect respiration. Corticosteroids may be used in treatment but do not appear to have an effect on the prognosis of duration of the disease. Rather, plasmapheresis or administration of high-dose immunoglobulin does result in shortening recovery time. The peripheral nerves of bot the sympathetic and parasympathetic nervous systems are involved in the disease and may lead to orthostatic hypotension, hypertension, and abnormal vagal responses affecting the heart. Gillian Barre syndrome may affect the lower brainstem qne CN's VII,VI,III,XII,V and X affecting facial, eye, and swallowing functions.

2. When planning care for the patient with trigeminal neuralgia, the nurse sets the highest priority on the patient outcome of.. a. relief of pain b. protection of the cornea c. maintenance of nutrition d. maintenance of positive body image

A. the pain of trigeminal neuralgia is excruciating, and it may occur in clusters that continue for hours. The condition is considered benign with not major effects except the pain. Corneal exposure is the problem in Bell's palsy or it may occur following surgery for the treatment of trigeminal neuralgia and patients then avoid eating . Except during an attack , there is no charge in facial appearance in a patient with trigeminal neuralgia and body image is more disturbed in response to the paralysis typical of Bell's palsy.

26. A patient with paraplegia has developed an irritable bladder with reflex emptying. The nurse teaches the patient .. A. Hygiene care for an indwelling urinary catheter b. how to perform intermitted self-catheterization C. to empty the bladder with manual pelvic pressure in coordination with reflex voiding patterns. d. that a urinary diversion such as an ileal conduit is the easiest way to handle urinary eliminations.

B. Intermittent self catheterization five to six times a day is the recommended method of bladder management for the patient whit a spinal cord injury because it more closely mimics normal emptying and has less potential for infection. The patient and family should be taught the procedure using clean technique and if the patient has use of the Ares self catheterization should be performed. Indwelling catheterization is used during the acute phase to prevent overdistention of the bladder and surgical urinary diversions are used if urinary complications occur.

13. Two days after a spinal cord injury, a patient asks continually about the extent of impairment that will result from the injury. The best response by the nurse is .. a. you will have more normal function when spinal shock resolves and the reflex returns. b. the extent of your injury cannot be determined until the secondary injury to the cord is resolved. c. when your condition is more stable an MRI will be done that can reveal the extent of the cord damage. d. because long term rehabilitation can affect the return of function, it will be years before we can tell what the complete effect will be.

B. Until the edema and necrosis at the site of the injury are resolved in 72hrs to 1 week after the injury, it is not possible to determine how much cord damage is present from the initial injury how much secondary injury occurred or how much the cord was damaged due by edema that extended above the level of the original injury . the return of reflexes signals only the end of spinal shock and the reflexes may be inappropriate and excessive, causing spasms that complicate rehabilitation.

9. A patient is admitted with spinal cord injury at the C7 level. During assessment the nurse identifies the presence of spinal shock on finding.. a. paraplegia with flaccid paralysis .b. tetraplegia with total sensory loss c. total hemiplegia with sensory and motor loss d. spastic tetraplegia with loss of pressure sensation

B. at the C7 level spinal shock is manifested by tetraplegia and sensory loss. The neurologic loss may be temporary or permanent. Paraplegia with sensory loss would occur at the level of T1. A hemiplegia occurs with central (brain) lesions affecting motor neurons and spastic tetraplegia occurs when spinal shock resolves.

24. A week following a spinal cord injury at T2 a patient experiences movement in his leg and tells the nurse he is recovering some function. The nurses best response is.. A. it's really too soon to know if you will have a return of the function. b. that could be a really positive finding , can you show me the movement? C. that's wonderful, we will start exercising your legs more frequently now. d. I'm sorry, but the movement is only a reflex and does not indicate normal function

B. in 1 week following a spinal cord injury there may be a resolution of the edema of the injury and an end to spinal shock. when spinal shock ends reflex movement and spasms will occur which may be mistaken for the return of function but with the resolution of edema some normal function may also occur. It is important when movement occurs to determine whether the movement is voluntary and can be consciously controlled which would indicate some return of function.

29.a patient with a. metastatic tumor of the spinal cord is scheduled for removal of the tumor by a laminectomy. In planning postoperative care for the patient, the nurse recognizes that.. A. most cord tumors cause autodestruction of the cord as in traumatic injuries. b. metastatic tumors are commonly extramural lesions that can be removed completely C. radiation therapy is routinely administered following surgery for all malignant spinal tumors d. because complete removal of intramedullary tumors is not possible, the surgery is considered palliative.

B. most metastatic tumors are extramural lesions that may be removed successfully with surgery . most tumors of the spinal cord are slow growing do not cause audodestruction and with the exception of intramural intramedullary tumors can be removed with complete functional restoration radiation is used to treat metastatic tumors that are sensitive to radiation and that have caused only minor neurologic deficits in the patient radiation is also used to adjuvant therapy to surgery for intramedullary tumors

6 A patient with Gillian-Barre syndrome asks whether he is going to die as the paralysis spreads towards his chest. In responding to the patient the nurse knows that.. a. patients who require ventilatory support almost always die. b. death occurs when nerve damage affects the brain and manages. c. most patients with Gillian-bare syndrome make a compelte recovery. d. if death can be prevented, residual paralysis and sensory impairment are usually permanent.

C As nerve involvement ascends it is very frightening for the patient, but most patients with Gillian Barre syndrome recover completely with care. Patients also revover if ventilator support is provided during respiratory failure. Gillian Barre syndrome affects only peripheral nerves and doesn't affect the brain.

20. The health care provider has ordered IV dopamine (intropin) for a patient in the ER with a spinal cord injury. The nurse determines that the drug is having the desired effect when assessment findings include. a. a pulse rate of 68 b. respiratory rate of 24 c. blood pressure of 106/82 d. temperature of 96.8 F

C. Dopamine is a vasodepressor that is used to maintain blood pressure during states of hypotension that occur during neurogenic shock associated with spinal cord injury. Atropine would be used to treat Bradycardia. The temperature reflects some degree of poikilothermism, but this is not treated with medication.

11. An initial incomplete spinal cord injury often results in complete cord damage because off... a. edematous compression of the cord above the level of injury. b. continued trauma to the cord resulting from damage to stabilizing ligaments. c. infarction and necrosis of the cord caused by edema, hemorrhage, and metabolites. d. mechanical transaction of the cord by sharp vertebral bone fragments after the initial injury.

C. The primary injury of the spinal cord rarely affects the entire cord, but the Pathophysiology of secondary injury may result in damage that is the same as mechanical severance of the cord. Complete cord dissolution occurs through autodestruction of the cord by hemorrhage, edema, and the presences of metabolites and norepinephrine, resulting in anoxia and infarction of the cord. Edema resulting from the inflammatory response may increase the damage as it extends above and below the injury site.

4. When providing care for a patient with an acute attack of trigeminal neuralgia, the nurse should... a. carry out all hygiene and oral care for the patient b. use conversation to distract the patient from pain. c. maintain a quiet, comfortable, draft free environment. d. have the patient examine the mouth after each meal for residual food.

C. attacks of trigeminal neuralgia may be precipitated by hot or cold air movement on the face, jarring movements or talking the environment should be of moderate temperature and free of drafts and patients should not be expected to converse during the acute period. Patients often prefer to carry out their own care because they are afraid someone else may inadvertently injury them or precipitate an attack. The nurse should stress that oral hygiene be performed because the patients often avoid ti, but residual food in the mouth after eating occurs frequently with Bell's Palsy

12. A patient with a spinal cord injury has spinal shock. The nurse plans care for the patient based on the knowledge that... a. rehabilitation measures cannot be initiated until spinal shock has resolved. b. the patient will need continuous monitoring for hypotension, tachycardia, and hypoxemia. c. resolution of spinal shock is manifested by spasticity, hyperreflexia, and reflex emptying of the bladder. d. the patient will have complete loss of motor and sensory functions below the level of the injury, but autonomic functions are not affected

C. spinal shock occurs in about half of all people with acute spinal cord injury. In spinal shock the entire cord below the level of the lesion fails to function, resulting in flaccid paralysis and hypomotility of most processes without any reflex activity. Return of reflux activity signals the end of spinal shock. Sympathetic function is impaired below the level of the injury because sympathetic nerves leave the spinal cord at the thoracic and lumbar areas, and cranial parasympathetic nerves predominate in control over respiration, heart and all vessels and organs below the injury. neurogenic shock results from loss of vascular tone caused by the injury and is manifested by hypotension, peripheral vasodilator contraindicated during spinal shock and should be instituted if the patient's cardiopulmonary status is stable.

22. Following a T2 spinal cord injury , the patient develops paralytic ileus. While this condition is present the nurse anticipates that the patient will need. a. IV fluids b. tube feedings c. parenternal nutrition d. nasogastric suctioning

D. During the first 2 to 3 days after a spinal chord injury paralytic ileus may occur, and nasogastric suction must be used to remove secretions and gas from the GI tract until peristalsis resumes. IV fluids are used to maintain fluid balance but do not specifically relate to paralytic ileus. Tube feedings would be used only for patients who had difficulty swallowing and not until peristalsis returned; parenteral nutrition would be used only if the paralytic ileus was unusually prolonged

17. One indication for surgical therapy of the patient with a spinal cord injury is when.. a. there is incomplete cord lesion involvement b. the ligaments that support the spine are torn c. a high cervical injury causes loss of respiratory function. d. evidence of continued compression of the cord is apparent.

D. although surgical treatment of spinal cord injuries often depends on the preference of the health care provider surgery is usually indicated when there is continued compression of the cord by extrinsic forces or when there is evidence of cord compression. Other indications may include progressive neurologic deficit , compound fracture of the vertebrae, bony fragments and penetrating wounds of the cord.