NCLEX Qs 280 Exam 1: Saunders & Concepts for Nursing (neuro)

The nurse on the rehabilitation unit is caring for the following clients. Which client should the nurse assess first after receiving the change-of-shift report? 1. The client with a C6 SCI who is complaining of dyspnea and has crackles in the lungs. 2. The client with an L4 SCI who is crying and very upset about being discharged home. 3. The client with an L2 SCI who is complaining of a headache and feeling very hot. 4. The client with a T4 SCI who is unable to move the lower extremities.

1. The client with a C6 SCI who is complaining of dyspnea and has crackles in the lungs. This client has signs/symptoms of a respiratory complication and should be assessed first.

The nurse is teaching the client with MS about the use of corticosteroids for treatment. Which of the following statements, if made by the patient indicates correct understanding? A) I should watch for side effects such as euphoria and insomnia while taking this medication B) This medication will need to be administered for at least 2 weeks before I begin to see improvements in my condition C) The corticosteroids will reduce my chances of relapsing in the future D) I could see flu-like symptoms while taking this medication

A) I should watch for side effects such as euphoria and insomnia while taking this medication Some side effects of corticosteroid use include euphoria, mood changes, and insomnia. This medication should only be used for short periods of time (3-5 days) and is often tapered off. This medication is for use in shortening the duration of a relapse, not preventing relapse. Flu-like medications are often seen in Interferon beta-1a or 1b medications (Betaseron, avonex) which are used to for long-term treatment of MS.

A young adult client complains of blurred vision and muscle spasms that come and go over the past several months. On what information from the client's history should the nurse focus to help identify this help problem? A) Family history of Parkinson disease B) Family history of epilepsy C) Is an immigrant from Germany D) Has been depressed

C) Is an immigrant from Germany Explanation: A) Multiple sclerosis is primarily a disease of people of northern European ancestry. The onset of multiple sclerosis is usually between the ages of 20 and 50, with the peak at age 30. Family history of epilepsy, Parkinson disease, and depression are important items of the client's history but do not support a diagnosis of MS.

Which of the following clinical manifestations would the nurse interpret as representing neurogenic shock in a patient with acute spinal cord injury? A) Bradycardia B) Hypertension C) Neurogenic spasticity D) Bounding pedal pulses

Correct Answer(s): A Neurogenic shock is due to the loss of vasomotor tone caused by injury and is characterized by hypotension and bradycardia. Loss of sympathetic innervation causes peripheral vasodilation, venous pooling, and a decreased cardiac output.

The nurse and the unlicensed assistive personnel (UAP) are caring for clients on a medical-surgical unit. Which task should not be assigned to the UAP? 1. Feed the 69-year-old client diagnosed with Parkinson's disease who is having difficulty swallowing. 2. Turn and position the 89-year-old client diagnosed with a pressure ulcer secondary to Parkinson's disease. 3. Assist the 54-year-old client diagnosed with Parkinson's disease with toilet-training activities. 4. Obtain vital signs on a 72-year-old client diagnosed with pneumonia secondary to Parkinson's disease.

1. Feed the 69-year-old client diagnosed with The nurse should not delegate feeding a client who is at risk for complications during feeding. This requires judgment that the UAP is not expected to possess.

The rehabilitation nurse caring for the client with an L1 SCI is developing the nursing care plan. Which intervention should the nurse implement? 1. Keep oxygen via nasal cannula on at all times. 2. Administer low-dose subcutaneous anticoagulants. 3. Perform active lower extremity ROM exercises. 4. Refer to a speech therapist for ventilator-assisted speech.

2 Deep vein thrombosis (DVT) is a potential complication of immobility,which can occur because the client cannot move the lower extremities as a result of the L1 SCI. Low-dose anticoagulation therapy (Lovenox)helps prevent blood from coagulating,thereby preventing DVTs.

A client has a neurological deficit involving the limbic system. Which assessment finding is specific to this type of deficit? 1. Is disoriented to person, place, and time 2. Affect is flat, with periods of emotional lability 3. Cannot recall what was eaten for breakfast today 4. Demonstrates inability to add and subtract; does not know who is the president of the United States

2. Affect is flat, with periods of emotional lability The limbic system is responsible for feelings (affect) and emotions. Calculation ability and knowledge of current events relate to function of the frontal lobe. The cerebral hemispheres, with specific regional functions, control orientation. Recall of recent events is controlled by the hippocampus.

The nurse is conducting a support group for clients diagnosed with Parkinson's disease and their significant others. Which information regarding psychosocial needs should be included in the discussion? 1. The client should discuss feelings about being placed on a ventilator. 2. The client may have rapid mood swings and become easily upset. 3. Pill-rolling tremors will become worse when the medication is wearing off. 4. The client may automatically start to repeat what another person says.

2. The client may have rapid mood swings and become easily upset. These are psychosocial manifestations of PD. These should be discussed in the support meeting.

The client diagnosed with Parkinson's disease is being discharged. Which statement made by the significant other indicates an understanding of the discharge instructions? 1. "All of my spouse's emotions will slow down now just like his body movements." 2. "My spouse may experience hallucinations until the medication starts working." 3. "I will schedule appointments late in the morning after his morning bath." 4. "It is fine if we don't follow a strict medication schedule on weekends."

3. "I will schedule appointments late in the morning after his morning bath." Scheduling appointments late in the morning gives the client a chance to complete ADLs without pressure and allows the medications time to give the best benefits.

The 30-year-old female client is admitted with complaints of numbness, tingling, a crawling sensation affecting the extremities, and double vision which has occurred two(2) times in the month. Which question is most important for the nurse to ask the client? 1. "Have you experienced any difficulty with your menstrual cycle?" 2. "Have you noticed a rash across the bridge of your nose?" 3. "Do you get tired easily and sometimes have problems swallowing?" 4. "Are you taking birth control pills to prevent conception?"

3.These are clinical manifestation of MS and can go un diagnosed for years be-cause of the remitting-relapsing nature of the disease. Fatigue and difficulty swallowing are other symptoms of MS. 1. MS does not affect the menstrual cycle. 2. A rash across the bridge of the nose suggests systemic lupus erythematosus 4. Taking birth control medications should not produce these symptoms or the pattern of occurrence.

The intensive care nurse is caring for a client with a T1 SCI. When the nurse elevates the head of the bed 30 degrees, the client complains of light headedness and dizziness. The client's vital signs are T 99.2 ̊F, P 98, R 24, and BP 84/40. Which action should the nurse implement? 1. Notify the health-care provider ASAP. 2. Calm the client down by talking therapeutically. 3. Increase the IV rate by 50 mL/hour. 4. Lower the head of the bed immediately.

4 For the first two (2) weeks after an SCI above T7, the blood pressure tends to be unstable and low; slight elevations of the head of the bed can cause profound hypotension; therefore, the nurse should lower the head of the bed immediately.

What is the underlying philosophy and focus of rehabilitation? 1. Patient's need and wants 2. Disabilities of the patient 3. Creative talents of the patient 4. Abilities of the patient

4. Abilities of the patient The focus is on the patient's abilities rather than disabilities, and continually to make the most of the abilities that remain intact

A client with C7 quadriplegia is flushed and anxious and complains of a pounding headache. Which of the following symptoms would also be anticipated? A. Decreased urine output or oliguria B. Hypertension and bradycardia C. Respiratory depression D. Symptoms of shock

B Hypertension, bradycardia, anxiety, blurred vision, and flushing above the lesion occur with autonomic dysreflexia due to uninhibited sympathetic nervous system discharge. The other options are incorrect

Which of the following conditions indicates that spinal shock is resolving in a client with C7 quadriplegia? A. Absence of pain sensation in chest B. Spasticity C. Spontaneous respirations D .Urinary continence

B Spasticity, the return of reflexes, is a sign of resolving shock. Spinal or neurogenic shock is characterized by hypotension, bradycardia, dry skin, flaccid paralysis, or the absence of reflexes below the level of injury. The absence of pain sensation in the chest doesn't apply to spinal shock. Spinal shock descends from the injury, and respiratory difficulties occur at C4 and above.

A patient with a paraplegia resulting from a T10 spinal cord injury has a neurogenic reflex bladder. When the nurse develops a plan of care for this problem, which nursing action will be most appropriate? a. Teaching the patient how to self-catheterize b. Assisting the patient to the toilet q2-3hr c. Use of the Credé method to empty the bladder d. Catheterization for residual urine after voiding

Correct Answer(s): A Rationale: Because the patient's bladder is spastic and will empty in response to overstretching of the bladder wall, the most appropriate method is to avoid incontinence by emptying the bladder at regular intervals through intermittent catheterization. Assisting the patient to the toilet will not be helpful because the bladder will not empty. The Credé method is more appropriate for a bladder that is flaccid, such as occurs with a reflexic neurogenic bladder. Catheterization after voiding will not resolve the patient's incontinence.

A client with a C6 spinal injury would most likely have which of the following symptoms? A: Aphasia B: Hemiparesis C:Paraplegia D: Tetraplegia

D Tetraplegia occurs as a result of cervical spine injuries. Paraplegia occurs as a result of injury to the thoracic cord and below.

The nurse is evaluating the neurological signs of a client in spinal shock following spinal cord injury. Which observation indicates that spinal shock persists? 1. Hyperreflexia 2. Positive reflexes 3. Flaccid paralysis 4. Reflex emptying of the bladder

3. Flaccid paralysis Resolution of spinal shock is occurring when there is return of reflexes (especially flexors to noxious cutaneous stimuli), a state of hyperreflexia rather than flaccidity, and reflex emptying of the bladder.

What is the earliest sign of increased intracranial pressure? 1. Widening pulse pressure 2. Ipsilateral pupil dilation 3. Ataxic breathing pattern 4. Change in level of consciousness (LOC)

4. Change in level of consciousness (LOC) A change in LOC is the earliest sign of increased intracranial pressure. This change in LOC may include disorientation, restlessness, or lethargy. Widening pulse pressure occurs because of an increased systolic blood pressure (due to excitation of vasoconstrictor fibers from ischemia of the vasomotor center) coupled with a stable diastolic blood pressure. This occurs later in the process of increased intracranial pressure, when herniation is imminent. Ipsilateral pupil dilation will occur due to compression of cranial nerve III (oculomotor) when the lesion is in one hemisphere. This occurs later in the process of increased intracranial pressure, when herniation is imminent. An ataxic breathing pattern is an irregular and unpredictable breathing pattern with random, shallow, and deep breaths and occasional pauses. This will occur very late in the process of increased intracranial pressure.

The nurse is assessing a 48-year-old client diagnosed with multiple sclerosis. Which clinical manifestation warrants immediate intervention? 1. The client has scanning speech and diplopia. 2. The client has dysarthria and scotomas. 3. The client has muscle weakness and spasticity. 4. The client has a congested cough and dysphagia.

4.Dysphagia is a common problem of clients diagnosed with multiple sclerosis,and this places the client at risk for aspiration pneumonia. Some clients diagnosed with multiple sclerosis eventually become immobile and are at risk for pneumonia. 1, 2, 3: These are clinical manifestations of multiple sclerosis and are expected.

The nurse is caring for a client with a T5 complete spinal cord injury. Upon assessment, the nurse notes flushed skin, diaphoresis above the T5, and a blood pressure of 162/96. The client reports a severe, pounding headache. Which of the following nursing interventions would be appropriate for this client? Select all that apply. A. Elevate the HOB to 90 degrees B. Loosen constrictive clothing C. Use a fan to reduce diaphoresis D. Assess for bladder distention and bowel impaction E. Administer antihypertensive medication

A B D E The client has signs and symptoms of autonomic dysreflexia. The potentially life-threatening condition is caused by an uninhibited response from the sympathetic nervous system resulting from a lack of control over the autonomic nervous system. The nurse should immediately elevate the HOB to 90 degrees and place extremities dependently to decrease venous return to the heart and increase venous return from the brain. Because tactile stimuli can trigger autonomic dysreflexia, any constrictive clothing should be loosened. The nurse should also assess for distended bladder and bowel impaction, which may trigger autonomic dysreflexia, and correct any problems. Elevated blood pressure is the most life-threatening complication of autonomic dysreflexia because it can cause stroke, MI, or seizures. If removing the triggering event doesn't reduce the client's blood pressure, IV antihypertensives should be administered. A fan shouldn't be used because cold drafts may trigger autonomic dysreflexia

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. 1. Keeping the linens wrinkle-free under the client 2. Preventing unnecessary pressure on the lower limbs 3. Limiting bladder catheterization to once every 12 hours 4. Turning and repositioning the client at least every 2 hours 5. Ensuring that the client has a bowel movement at least once a week

ANS 1, 2 ,4 The most frequent cause of autonomic dysreflexia is a distended bladder. Straight catheterization should be done every 4 to 6 hours (catheterization every 12 hours is too infrequent), and urinary catheters should be checked frequently to prevent kinks in the tubing. Constipation and fecal impaction are other causes, so maintaining bowel regularity is important. Ensuring a bowel movement once a week is much too infrequent. Other causes include stimulation of the skin from tactile, thermal, or painful stimuli. The nurse administers care to minimize risk in these areas. Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process: Implementation Content Area: Adult Health: Neurological Strategy(ies): Subject Priority Concepts: Caregiving, Intracranial Regulation

A male patient suffered a spinal cord injury that has left him a quadriplegic. He has paralysis of the lower and upper extremities but is able to breathe on his own. What would be the most appropriate nursing diagnoses for this patient? SATA 1. Risk for impaired skin integrity related to the lack of movement 2. Impaired physical mobility related to injury process 3. Ineffective breathing pattern related to spinal injury 4. Acute pain related to disease process 5. Grieving related to loss of functions

ANS 1, 2, 5 These nursing diagnoses would be appropriate for this patient based on the information given. A diagnosis of ineffective breathing pattern is inappropriate because of the report that the patient can breathe on his own. A diagnosis of acute pain is inappropriate because generally paralysis affects the pain centers in such a way that the paralyzed patient feels no pain.

The nurse will implement which of these nursing interventions for the patient with increased intracranial pressure? SATA 1. Place neck in neutral position. 2. Keep head of the bed angled 10° to 20°. 3. Force fluids up to 2 L/day unless otherwise contraindicated. 4. Teach patient to avoid Valsalva maneuver. 5. Position patient to avoid flexion of hips, waist, and neck. 6. Suction only as necessary, but no longer than 10 seconds.

ANS 1, 4, 5, 6 The neck of a patient with increased intracranial pressure must be kept in a neutral position to promote venous drainage. It should not be flexed or extended. The patient should be instructed to avoid the Valsalva maneuver. This needs to be explained to the patient in terms that he or she can easily understand. The patient needs to be positioned in such a way that the hips, waist, and neck are not flexed. Rotation of the head, especially to the right, also must be avoided. Extreme hip flexion causes an increase in intra-abdominal and intrathoracic pressure, which can trigger a rise in intracranial pressure. The patient must be suctioned only when absolutely necessary (and for no longer than 10 seconds) as this can increase the intracranial pressure of the patient. In addition, the patient should be hyperoxygenated with 100% oxygen before and after suctioning to prevent a decrease in PaO2. The head of the bed of a patient with increased intracranial pressure needs to be kept at 30° to 45°, which promotes venous return. The patient with increased intracranial pressure will be on a fluid restriction.

32-year-old client recently diagnosed with multiple sclerosis is a full-time aerobics exercise instructor at a local fitness center. Which statements contain the correct information to give the client when answering her specific questions about lifestyle? Select all that apply. A) "Hyperbaric oxygen treatment is recommended prior to vigorous physical exercise." B) "You will tolerate exercise better in an air-conditioned room." C) "Acupuncture may benefit some of your symptoms." D) "Drinking cold water is recommended during exercise." E) "You will be able to maintain your exercise teaching schedule."

Answer: B, C, D Explanation: A) Symptoms of MS are exacerbated by increased body temperature. Exercising in a cold room and drinking cold beverages keep body temperature down. Acupuncture has low risk and may be beneficial for some symptoms. Hyperbaric oxygen therapy carries more risk than benefit. It is unlikely that a newly diagnosed client with MS will be able to tolerate a full-time exercise instructor role.

Which of the following interventions describes an appropriate bladder program for a client in rehabilitation for spinal cord injury? A. Insert an indwelling urinary catheter to straight drainage B. Schedule intermittent catheterization every 2 to 4 hours C. Perform a straight catheterization every 8 hours while awake D. Perform Crede's maneuver to the lower abdomen before the client voids.

B Intermittent catherization should begin every 2 to 4 hours early in the treatment. When residual volume is less than 400 ml, the schedule may advance to every 4 to 6 hours. Indwelling catheters may predispose the client to infection and are removed as soon as possible. Crede's maneuver is not used on people with spinal cord injury.

A client is admitted with a spinal cord injury at the level of T12. He has limited movement of his upper extremities. Which of the following medications would be used to control edema of the spinal cord? A. Acetazolamide (Diamox) B. Furosemide (Lasix) C. Methylprednisolone (Solu-Medrol) D. Sodium Bicarbonate

C High doses of Solu-Medrol are used within 24 hours of spinal injury to reduce cord swelling and limit neurological deficit. The other drugs aren't indicated in this circumstance.

The nurse is planning care for the client in spinal shock. Which of the following actions would be least helpful in minimizing the effects of vasodilation below the level of the injury? A. Monitoring vital signs before and during position changes B. Using vasopressor medications as prescribed C. Moving the client quickly as one unit D. Applying Teds or compression stockings.

C Reflex vasodilation below the level of the spinal cord injury places the client at risk for orthostatic hypotension, which may be profound. Measures to minimize this include measuring vital signs before and during position changes, use of a tilt-table with early mobilization, and changing the client's position slowly. Venous pooling can be reduced by using Teds (compression stockings) or pneumatic boots. Vasopressor medications are administered per protocol.

The nurse is evaluating neurological signs of the male client in spinal shock following spinal cord injury. Which of the following observations by the nurse indicates that spinal shock persists? A. Positive reflexes B. Hyperreflexia C. Inability to elicit a Babinski's reflex D. Reflex emptying of the bladder

C Resolution of spinal shock is occurring when there is a return of reflexes (especially flexors to noxious cutaneous stimuli), a state of hyperreflexia rather than flaccidity, reflex emptying of the bladder, and a positive Babinski's reflex.

A 30-year-old was admitted to the progressive care unit with a C5 fracture from a motorcycle accident. Which of the following assessments would take priority? A Bladder distension B Neurological deficit C pulse ox readings D The client's feelings about the injury

C After a spinal cord injury, ascending cord edema may cause a higher level of injury. The diaphragm is innervated at the level of C4, so assessment of adequate oxygenation and ventilation is necessary. Although the other options would be necessary at a later time, observation for respiratory failure is the priority.

While in the ER, a client with C8 tetraplegia develops a blood pressure of 80/40, pulse 48, and RR of 18. The nurse suspects which of the following conditions? A. Autonomic dysreflexia B. Hemorrhagic shock C. Neurogenic shock D. Pulmonary embolism

C Symptoms of neurogenic shock include hypotension, bradycardia, and warm, dry skin due to the loss of adrenergic stimulation below the level of the lesion. Hypertension, bradycardia, flushing, and sweating of the skin are seen with autonomic dysreflexia. Hemorrhagic shock presents with anxiety, tachycardia, and hypotension; this wouldn't be suspected without an injury. Pulmonary embolism presents with chest pain, hypotension, hypoxemia, tachycardia, and hemoptysis; this may be a later complication of spinal cord injury due to immobility.

1) A client diagnosed with multiple sclerosis has an acute onset of visual changes, fatigue, and leg weakness. The client says that the last time this happened, recovery occurred in a few weeks. Which classification of multiple sclerosis is the client experiencing? A) Progressive-relapsing B) Secondary-progressive C) Relapsing-remitting D) Primary-progressive

C) Relapsing-remitting Explanation: A) There are four classifications of multiple sclerosis. The client has an exacerbation of symptoms and has a history of full recovery. This is classified as relapsing-remitting and is the most common type. Primary-progressive is a steady worsening of the disease with occasional minor recovery. Secondary-progressive begins as relapsing-remitting but the disease becomes worse between exacerbations. Progressive-relapsing is rare, with the disease progressing from the onset with periods of exacerbation.

A client has a cervical spine injury at the level of C5. Which of the following conditions would the nurse anticipate during the acute phase? A. Absent corneal reflex B. Decerebrate posturing C. Movement of only the right or left half of the body D. The need for mechanical ventilation

D The diaphragm is stimulated by nerves at the level of C4. Initially, this client may need mechanical ventilation due to cord edema. This may resolve in time. Absent corneal reflexes, decerebrate posturing, and hemiplegia occur with brain injuries, not spinal cord injuries.

A 25-year-old patient has returned home following extensive rehabilitation for a C8 spinal cord injury. The home care nurse visits and notices that the patient's spouse and parents are performing many of the activities of daily living (ADLs) that the patient had been managing during rehabilitation. The most appropriate action by the nurse at this time is to a. tell the family members that the patient can perform ADLs independently. b. remind the patient about the importance of independence in daily activities. c. recognize that it is important for the patient's family to be involved in the patient's care and support their activities. d. develop a plan to increase the patient's independence in consultation with the with the patient, spouse, and parents.

Correct Answer((s): D Rationale: The best action by the nurse will be to involve all the parties in developing an optimal plan of care. Because family members who will be assisting with the patient's ongoing care need to feel that their input is important, telling the family that the patient can perform ADLs independently is not the best choice. Reminding the patient about the importance of independence may not change the behaviors of the family members. Supporting the activities of the spouse and parents will lead to ongoing dependency by the patient.

A patient with a history of a T2 spinal cord tells the nurse, "I feel awful today. My head is throbbing, and I feel sick to my stomach." Which action should the nurse take first? a. Notify the patient's health care provider. b. Check the blood pressure (BP). c. Give the ordered antiemetic. d. Assess for a fecal impaction.

Correct Answer(s): B Rationale: The BP should be assessed immediately in a patient with an injury at the T6 level or higher who complains of a headache to determine whether autonomic dysreflexia is causing the symptoms, including hypertension. Notification of the patient's health care provider is appropriate after the BP is obtained. Administration of an antiemetic is indicated after autonomic dysreflexia is ruled out as the cause of the nausea. The nurse may assess for a fecal impaction, but this should be done after checking the BP and lidocaine jelly should be used to prevent further increases in the BP.

A patient with a T1 spinal cord injury is admitted to the intensive care unit (ICU). The nurse will teach the patient and family that a. use of the shoulders will be preserved. b. full function of the patient's arms will be retained. c. total loss of respiratory function may occur temporarily. d. elevations in heart rate are common with this type of injury.

Correct Answer(s): B Rationale: The patient with a T1 injury can expect to retain full motor and sensory function of the arms. Use of only the shoulders is associated with cervical spine injury. Total loss of respiratory function occurs with injuries above the C4 level and is permanent. *Bradycardia is associated with injuries above the T6 level.*

The nurse is caring for a patient admitted with a spinal cord injury following a motor vehicle accident. The patient exhibits a complete loss of motor, sensory, and reflex activity below the injury level. The nurse recognizes this condition as which of the following? A) Central cord syndrome B) Spinal shock syndrome C) Anterior cord syndrome D) Brown-Séquard

Correct Answer(s): B About 50% of people with acute spinal cord injury experience a temporary loss of reflexes, sensation, and motor activity that is known as spinal shock. Central cord syndrome is manifested by motor and sensory loss greater in the upper extremities than the lower extremities. Anterior cord syndrome results in motor and sensory loss but not reflexes. Brown-Séquard syndrome is characterized by ipsilateral loss of motor function and contralateral loss of sensory function.

When caring for a patient who had a C8 spinal cord injury 10 days ago and has a weak cough effort, bibasilar crackles, and decreased breath sounds, the initial intervention by the nurse should be to a. administer oxygen at 7 to 9 L/min with a face mask. b. place the hands on the epigastric area and push upward when the patient coughs. c. encourage the patient to use an incentive spirometer every 2 hours during the day. d. suction the patient's oral and pharyngeal airway.

Correct Answer(s): B Rationale: The nurse has identified that the cough effort is poor, so the initial action should be to use assisted coughing techniques to improve the ability to mobilize secretions. Administration of oxygen will improve oxygenation, but the data do not indicate hypoxemia, and oxygen will not help expel respiratory secretions. The use of the spirometer may improve respiratory status, but the patient's ability to take deep breaths is limited by the loss of intercostal muscle function. Suctioning may be needed if the patient is unable to expel secretions by coughing but should not be the nurse's first action.

The nurse is caring for a patient admitted 1 week ago with an acute spinal cord injury. Which of the following assessment findings would alert the nurse to the presence of autonomic dysreflexia? A) Tachycardia B) Hypotension C) Hot, dry skin D) Throbbing headache

Correct Answer(s): D Autonomic dysreflexia is related to reflex stimulation of the sympathetic nervous system reflected by hypertension, bradycardia, throbbing headache, and diaphoresis.

A 70 yr old patient who has a spinal cord injury at C8 resulting in central cord syndrome. Which effect of the patient's most likely to be life threatening after completeing rehabiliation? A. increased bone density loss B. higher risk for tissue hypoxia C. vasomotor compensation lost D. Weakness of thoracic muscles

Correct Answer(s): D Weakness of thoracic muscle is most likely to cause life-threatening complications because affects patients oxygenation and ventilation.

A patient with a neck fracture at the C5 level is admitted to the intensive care unit (ICU) following initial treatment in the emergency room. During initial assessment of the patient, the nurse recognizes the presence of spinal shock on finding a. hypotension, bradycardia, and warm extremities. b. involuntary, spastic movements of the arms and legs. c. the presence of hyperactive reflex activity below the level of the injury. d. flaccid paralysis and lack of sensation below the level of the injury.

Correct Answer(s): D Rationale: Clinical manifestations of spinal shock include decreased reflexes, loss of sensation, and flaccid paralysis below the area of injury. Hypotension, bradycardia, and warm extremities are evidence of neurogenic shock. Involuntary spastic movements and hyperactive reflexes are not seen in the patient at this stage of spinal cord injury.

The nurse is caring for a man who has experienced a spinal cord injury. Throughout his recovery, the client expects to gain control of his bowels. The nurse's best response to this client would be which of the following? a. "Over time, the nerve fibers will regrow new tracts, and you can have bowel movements again." b. "Wearing an undergarment will become more comfortable over time." c "Having a bowel movement is a spinal reflex requiring intact nerve fibers. Yours are not intact." d "It is not going to happen. Your nerve cells are too damaged."

Correct Answer(s: ) C Having a bowel movement is a spinal reflex requiring intact nerve fibers. Yours are not intact The act of defecation is a spinal reflex involving the parasympathetic nerve fibers. Normally, the external anal sphincter is maintained in a state of tonic contraction. With a spinal cord injury, the client no longer has this nervous system control and is often incontinent.

A 25-yr old male pt who is a professional motocross racer has anterior spinal cord syndrome at T10. His history includes tobacco use, alcohol abuse, marijuana abuse. What is the nurse's priority during rehabilitation? A. Monitor the patient 4 times an hour B. Encourage him to verbalize feeling. C. Prevent urniary tract infection D. Teach about using gastrocolic reflex

Correct answer(s) B The pt is at high risk for depression and self-injury because he is likely to lose function below the umbilicus . resulting in loss motor function. In addition he will need to be in a wheelchair, impaired sexual function, and can not use tobacco, alcohol, marijuana abuse for coping.

The nurse is caring for a client admitted with spinal cord injury. The nurse minimizes the risk of compounding the injury most effectively by: A. Keeping the client on a stretcher B. Logrolling the client on a firm mattress C. Logrolling the client on a soft mattress D. Placing the client on a Stryker frame

D Spinal immobilization is necessary after spinal cord injury to prevent further damage and insult to the spinal cord. Whenever possible, the client is placed on a Stryker frame, which allows the nurse to turn the client to prevent complications of immobility, while maintaining alignment of the spine. If a Stryker frame is not available, a firm mattress with a bed board should be used.

A 22-year-old client with quadriplegia is apprehensive and flushed, with a blood pressure of 210/100 and a heart rate of 50 bpm. Which of the following nursing interventions should be done first? A. Place the client flat in bed B. Assess patency of the indwelling urinary catheter C. Give one SL nitroglycerin tablet D. raise the head of the bed immediately to 90 degrees

D Anxiety, flushing above the level of the lesion, piloerection, hypertension, and bradycardia are symptoms of autonomic dysreflexia, typically caused by such noxious stimuli such as a full bladder, fecal impaction, or decubitus ulcer. Putting the client flat will cause the blood pressure to increase even more. The indwelling urinary catheter should be assessed immediately after the HOB is raised. Nitroglycerin is given to reduce chest pain and reduce preload; it isn't used for hypertension or dysreflexia.