NEURO 1
You are preparing to discharge a client with chronic low back pain. Which statement by the client indicates the need for additional teaching? 1.) "I will avoid exercise because the pain gets worse." 2.) "I will use heat or ice to help control the pain." 3.) "I will not wear high-heeled shoes at home or work." 4.) "I will purchase a form mattress to replace my old one."
1.) "I will avoid exercise because the pain gets worse."
What does the nurse do for a client with a cervical laminectomy that differs from the nursing care for a client with a lumbar laminectomy? 1.) assist with the removal of oral secretions 2.) maintain the client's head in a flexed position 3.) elevate the head of the client's bed to a 45 degree angle 4.) provide range of motion exercise early during the post operative period
1.) assist with the removal of oral secretions
A client with a spinal cord injury has paraplegia. the nurse assesses for which major problem the client may experience early in the recovery period? 1.) bladder control 2.) nutritional intake 3.) quadriceps setting 4.) use of aid for ambulation
1.) bladder control
A client with a cervical SCI has been placed in fixed skeletal traction with a halo fixation device. When caring for the client, the nurse may delegate which actions to the LPN/LVN? select all that apply 1.) checking the patients skin for pressure from the device 2.) assessing the client's neurologic status for changes 3.) observing the halo insertion sites for signs of infection 4.) cleaning the halo insertion sites with hydrogen peroxide 5.) developing the nursing plan of care for the client
1.) checking the patients skin for pressure from the device 3.) observing the halo insertion sites for signs of infection 4.) cleaning the halo insertion sites with hydrogen peroxide
A nurse expects a client with a herniated intervertebral disk to report a sudden increase in pain with which activities? select all that apply 1.) coughing and sneezing 2.) sitting on cold surface 3.) standing for extended periods 4.) lying supine whole flexing the knees 5.) straining when having a bowel movement
1.) coughing and sneezing 5.) straining when having a bowel movement
A nurse finds a victim under the wreckage of a collapsed building. the individual is conscious, supine, breathing satisfactorily, and reporting back pain and an inability to move the legs. Which action should the nurse take first? 1.) leave individual lying on the back with instructions not to move, and seek additional help. 2.) roll the individual onto the abdomen, place a pad under the head, and cover with any material available 3.) gently raise the individual to a sitting position to see whether the pain either diminishes or increases in intensity 4.) gently lift the individual onto a flat piece of lumbar and , using any available transportation, rush to the closed medical institution
1.) leave individual lying on the back with instructions not to move, and seek additional help.
After a client is treated for a spinal cord injury, the health care provider informs the family that the client is paraplegic. the family asks the nurse what this means. what explanation should the nurse provide? 1.) lower extremities are paralyzed 2.) upper extremities are paralyzed 3.) one side of the body is paralyzed 4.) both lower and upper extremities are paralyzed
1.) lower extremities are paralyzed
What clinical indicator does the nurse expect to identify when assessing a client admitted with a herniated lumbar disk? 1.) pain radiating to the hip and leg 2.) boweland bladder incontinence 3.) paralysis of both lower legs 4.) overgrowth of tissue on lower back
1.) pain radiating to the hip and leg
you are helping a client with an SCI to establish bladder retraining program. which strategies may simulate the client to void? select all that apply 1.) stroking the clients inner thigh 2.) pulling on the client's pubic hair 3.) initiating intermittent straight catheterization 4.) pouring warm water over the clients perineum 5.) tapping the bladder to stimulate the detrusor muscle
1.) stroking the clients inner thigh 2.) pulling on the client's pubic hair 4.) pouring warm water over the clients perineum 5.) tapping the bladder to stimulate the detrusor muscle
A nurse is a rehabilitation center teaches clients with quadriplegia to use an adaptive wheelchair. why is it important that the nurse provide this instruction? 1.) they usually will never walk 2.) it prepares them for wearing braces 3.) it assists them in overcoming orthostatic hypotension 4.) they have the strength in the upper extremities for self- transfer
1.) they usually will never walk
A client is in the intensive care unit after sustaining a T2 spinal cord injury. Which priority interventions should the nurse include in the client's plan of care? select all that apply 1.) minimizing environmental stimuli 2.) assessing for respiratory complications 3.) monitoring and maintaining blood pressure 4.) initiating a bowel and bladder training program 5.) discussing long-term treatment plans with the family
2.) assessing for respiratory complications 3.) monitoring and maintaining blood pressure
A client with a spinal cord injury (SCI) reports sudden severe throbbing headache that started a short time ago. Assessment if the client reveals increased blood pressure (169.94mmhg) and decreased heart rate (48 beats/min), diaphoresis, and flushing of the face and neck. what action should you take first? 1.) administer ordered acetaminophen (tylenol) 2.) check the foley tubing for kinks and obstructions 3.) adjust the temperature in the clients room 4.) notify the physician about the change in status
2.) check the foley tubing for kinks and obstructions
A client has paraplegia as a result of a motorcycle accident. what is the reason the nursing care plan should include turning the client ever 1 to 2 hours? 1.) maintain comfort 2.) prevent pressure ulcers 3.) prevent flexion contractures of the extremities 4.) improve venous circulation in the lower extremities
2.) prevent pressure ulcers
What should the nurse include in the plan of care for a client who just had a posterior lumbar laminectomy? 1.) encourage the client to cough 2.) reposition the client by log rolling 3.) asses the client for indications of peritonitis 4.) instruct the client to bend the knees when turning
2.) reposition the client by log rolling
For which clinical indicator should the nurse assess a client who just had a microdiskectomy for a herniated lumbar disk? 1.) cerebral edema 2.) sensory loss in legs 3.) spasms of the bladder 4.) pain referred to the flanks
2.) sensory loss in legs
You are floated from the ED to the neurologic floor. which action should you delegate to the UAP when providing nursing care for a client with a SCI? 1.) assessing the clients's respiratory status every 4 hours 2.) taking the client's vital signs and recording every 4 hours 3.) monitoring the client's nutritional status, including calorie intake 4.) instructing the client how to turn, cough and breathe deeply every 4 hours
2.) taking the client's vital signs and recording every 4 hours
A nurse is caring for a client with a spinal cord injury during the immediate post injury period. what is the primary focus of nursing care during this immediate phase? 1.) inhibiting urinary tract infections 2.) preventing contractures and atrophy 3.) avoiding flexion or hyperflexion of the spine 4.) preparing the client for vocational rehabilitation
3.) avoiding flexion or hyperflexion of the spine
A client has a functional transection of the spinal cord at C7-8, resulting in spinal shock. Which clinical indicators does the nurse expect to identify when assessing the client immediately after the injury? select all that apply 1.) spasticity 2.) incontinence 3.) flaccid paralysis 4.) respiratory failure 5.) lack of reflexes below the injury
3.) flaccid paralysis 5.) lack of reflexes below the injury
You are preparing a nursing care plan for a client with an SCI for whom the nursing diagnoses of impaired physical mobility and toileting self care deficit have been identifies. the client tells you " I don't know why we're doing all this. My life's over." based on this statement, which additional nursing diagnosis takes priority? 1.) risk for injury related to altered mobility 2.) imbalanced nutrition: less than body requirement 3.) impaired individual resilience related to spinal cord injury 4.) disturbed body image related to immobilization
3.) impaired individual resilience related to spinal cord injury
after having a traumatic spinal cord severance, a young client is having difficulty accepting paralysis. one day the client has severe leg spasms and says, "my strength is coming back, and I know I will walk again." The nurse's response should be based on what understanding? 1.) the nerves are regenerating and motor function is returning 2.) motor function may be returning now that the edema is subsiding 3.) spinal shock has subsided and the client's reflexes are hyperactive 4.) the client has developed thrombophlebitis and is experiencing pain
3.) spinal shock has subsided and the client's reflexes are hyperactive
A client with an SCI at level C3-C4 is being cared for in the ED. What is the priority assessment? 1.)determine the level at which the client has intact sensation 2.) assess the level at which the client has retained mobility 3.) check blood pressure and pulse for signs of spinal shock 4.) monitor respiratory effort and oxygen saturation
4.) monitor respiratory effort and oxygen saturation
A client with quadriplegia is placed on a tilt table daily. each day the angle of the head of the table gradually is increased. what should the nurse identify as its purpose when the client asks the reason for the tilt table? 1.) facilitates turning 2.) prevents pressure ulcers 3.) promotes hyperextension of the spine 4.) limits loss of calcium from the bones
4.) limits loss of calcium from the bones
A nurse should expect a client with a spinal cord injury to have some spasticity of the lower extremities. what should the nurse include in the plan of care for this client to prevent the development of lower extremity contractures? 1.) deep massage 2.) active exercise 3.) uses of tilt board 4.) proper positioning
4.) proper positioning
What problems the nurse primarily attempting to prevent when encouraging a client with a spinal cord injury to increase oral fluid intake? 1.) dehydration 2.) skin breakdown 3.) electrolyte imbalance 4.) urinary tract infection
4.) urinary tract infection
The nurse reviews the discharge and home care instructions with a patient who has back surgery. Which statement by the patient indicates further teaching is needed? A.) " I will drive myself to my doctor's office next week." B.) "I will put a piece of plywood under my mattress." C.) "I will try to increase fruits and vegetables and decrease fat intake." D.) "I plan to get a new ergonomic chair at work."
A.) " I will drive myself to my doctor's office next week."
A patient has just undergone spinal fusion surgery and returned from the operating room 12 hours ago. Which risk is best to delegate to the unlicensed assistive personal (UAP)? A.) Log-roll the patient every 2 hours B.) Help the patient dangle the legs on the evening of surgery C.) Assist the patient to put on a brace so he can get out of bed D.) Help the patient ambulate to the bathroom as needed
A.) Log-roll the patient every 2 hours
Which position is therapeutic and comfortable for a patient with lower back pain? A.) Semi-Fowler's position with a pillow under the knees to keep them flexed B.) Supine position with arms and legs in a correct anatomical position C.) Orthopneic position; sitting with trunk slightly forward; arms supported on a pillow D.) Modified Sim's position with upper arm and leg support by pillows
A.) Semi-Fowler's position with a pillow under the knees to keep them flexed
A patient has just undergone a spinal fusion and laminectomy and has returned from the operating room. Which assessment are done in the 24 hours? select all that apply A.) Take vital signs every 4 hours and assess for fever and hypotension B.) Perform a neurologic assessment every 4 hours with attention to movement and sensation C.) Monitor intake and output and assess for urinary retention D.) Assess for ability and independence in ambulating and moving in bed E.) Observe for clear fluid on or around the dressing
A.) Take vital signs every 4 hours and assess for fever and hypotension B.) Perform a neurologic assessment every 4 hours with attention to movement and sensation C.) Monitor intake and output and assess for urinary retention E.) Observe for clear fluid on or around the dressing
A patient is scheduled for lumbar surgery. Which key points must the nurse include in a preoperative teaching plan for this patient? select all that apply A.) Techniques for getting in and out of bed B.) Expectation for turning and moving in bed C.) Limitations and restrictions for home activities D.) Restriction of bedrest for at least 48 hours E.) Report any numbness and tingling to the nurse immediately
A.) Techniques for getting in and out of bed B.) Expectation for turning and moving in bed C.) Limitations and restrictions for home activities E.) Report any numbness and tingling to the nurse immediately
Which neurologic assessment technique does the nurse use to test a patient for sensory function? A.) Touch the skin with a clean paper clip and ask whether it is a sharp or dull sensation B.) Ask the patient to elevate both arms off the bed and extend wrists and fingers C.) Have the patient close the eyes and move the toes up or down; the patient identifies the position D.) Have the patient sit with the legs dangling use a reflex hammer to test reflex responses
A.) Touch the skin with a clean paper clip and ask whether it is a sharp or dull sensation
Because the patient is at risk for spinal shock, what does the nurse monitor for? A.) decreased blood pressure, bradycardia, and decreased bowel sounds B.) Tachycardia and a change in the level of consciousness C.) Decreased respiratory rate and loss of sensation to pain and touch D.) Paralytic ileus and loss of bowel and bladder function
A.) decreased blood pressure, bradycardia, and decreased bowel sounds
The nurse is caring for a patient who has been in a long-term care facility for several months following an SCI. The patient has had problems with urinary retention and subsequent overflow incontinence, and a bladder retraining program was recently initiated. which are expected outcomes of the training program? select all that apply A.) demonstrates a predictable pattern of voiding B.) is able to independently catheterize himself C.) pours warm water over perineum to stimulate voiding D.) takes bethanechol chloride (urecholine)1 hour before voiding E.) is able to empty the bladder completely F.) does not experience a urinary tract infection
A.) demonstrates a predictable pattern of voiding E.) is able to empty the bladder completely F.) does not experience a urinary tract infection
What key point does the nurse include in teaching an SCI patient about bowel and bladder retraining? select all that apply A.) ensure the patient gets a sufficient quantity of fluid each day B.) instruct the patient about the purpose of stool softeners C.) teach the patient about high fiber foods D.) teach the patient that continence is dependent upon spinal cord healing E.) digital rectal stimulation is essential for regular bowel movement
A.) ensure the patient gets a sufficient quantity of fluid each day B.) instruct the patient about the purpose of stool softeners C.) teach the patient about high fiber foods
Which statements about spinal shock are accurate? select all that apply A.) it lasts for from less than 48 hours up to a few weeks B.) There is temporary loss of motor and sensory function C.) Theere is permanent loss of motor and sensory function D.) There is temporary loss of reflex and autonomic function E.) There is permanent loss of reflex and autonomic function
A.) it lasts for from less than 48 hours up to a few weeks B.) There is temporary loss of motor and sensory function D.) There is temporary loss of reflex and autonomic function
After suffering an SCI, a patient develops autonomic dysfunction, including a neurogenic bladder. What is the priority patient problem for this condition? A.) risk for urinary tract infection B.) risk for dehydration C.) risk for urinary retention D.) risk for urinary incontinence
A.) risk for urinary tract infection
What should the nurse asses for when a client with a cervical injury reports a severe headache and nasal congestion? A.) suprapubic distention 2.) increased penal reflexes 3.) adventitious breath sounds 4.) imminent development of shock
A.) suprapubic distention
The nurse is taking a history on an older adult patient who reports chronic back pain. The nurse seeks to identify factors that are contributing to the pain. Which question is the most useful in eliciting information? A.) "Have you had any recent falls or have you been in an accident?" B.) "Do you have a history of osteoarthritis?" C.) "Do you have a history of diabetes mellitus?" D.) "Are you having pain that radiates down your leg or into the buttocks?"
B.) "Do you have a history of osteoarthritis?"
The nurse is preparing to physically assess a patient's subjective report of paresthesia in the lower extremities. In order to accomplish this assessment, which assessment technique does the nurse use? A.) Use a doppler to locate the pedal pulse, the dorsals pedis pulse or the popliteal pulse. B.) Ask the patient to identify sharp and dull sensation by using a paper clip and cotton ball C.) Use a reflex hammer to test for deep tendon patellar or achilles reflexes D.) Ask the patient to walk across the room and observe his gait and equilibrium
B.) Ask the patient to identify sharp and dull sensation by using a paper clip and cotton ball
Which symptoms indicate that patient with a spinal cord injury is experiencing autonomic dysreflexia? select all that apply A.) Flaccid paralysis B.) Hypertension C.) Hypotension D.) severe headache E.) Blurred vision F.) Loss of reflexes below the injury
B.) Hypertension D.) severe headache E.) Blurred vision
The patient with chronic back pain is receiving ziconotide (Prialt) by intrathecal (spinal) infusion with a surgically implanted pump. The patient develops hallucinations. What is the nurse's best first action? A.) Request a psychiatric evaluation B.) Notify the health care provider C.) Perform an assessment of level of consciousness D.) Decrease the dose of the medication
B.) Notify the health care provider
Assessment of a patient with a lower spinal cord injury conforms that the patient has paralysis of the bilateral lower extremities. How does the nurse document this finding? A.) Paraparesis B.) Paraplegia C.) Quadriparesis D. Quadriplegia
B.) Paraplegia
The nurse is assessing a patient who presented to the emergency department (ED) reporting acute onset of numbness and tingling in the right leg. How does the nurse document this subjective finding? A.) Paraparesis B.) Paresthesia C.) Ataxia D.) Quadriparesis
B.) Paresthesia
The nurse is assessing a patient with spinal cord injury and recognizes the patient is experiencing autonomic dysreflexia. What is the nurse's first priority action? A.) Check for bladder distention B.) Raise the head of the bed C.) administer an antihypertensive medication D.) Notify the primary health care provider
B.) Raise the head of the bed
A patient has a long history of chronic back pain and has undergone several back surgeries in the past. At this point, the surgeon is recommending a surgical procedure for spine stabilization. Which procedure does the nurse anticipate this patient will need? A.) Laparoscopic diskectomy B.) Spinal fusion C.) Laminectomy D.) Traditional diskectomy
B.) Spinal fusion
A patient involved in a high-speed motor vehicle accident with sustained multiple injuries and active bleeding is transported to the emergency department by ambulance with immobilization devices in place. There is a high probability of cervical spine and extremities are flaccid. What is the priority assessment for this patient? A.) Check the mental status using the glasgow coma scale B.) assess the respiratory pattern and ensure a patent airway C.) Observe for intraabdominal bleeding and hemorrhage D.) Assess for loss of motor functioning sensation
B.) assess the respiratory pattern and ensure a patent airway
The nurse is caring for several patients with SCI's. Which task is best to delegate to the UAP? A.) encourage use of incentive spirometry; evaluate the patient's ability to use is correctly B.) log-roll the patient; maintain proper body alignment and place a bedpan for tolieting C.) check for skin breakdown under the immobilization device during bathing D.) Insert a foley catheter and report the amount and color of the urine
B.) log-roll the patient; maintain proper body alignment and place a bedpan for tolieting
The nurse is caring for a patient with a recent spinal cord injury (SCI). Which intervention does the nurse use to target and prevent the potential SCI complication of autonomic dysreflexia? select all that apply A.) frequently perform passive ROM exercises B.) loosen or remove any tight clothing C.) Monitor stool output and maintain a bowel program D.) keep the patient immobilized with neck or back brace E.) monitor urinary output and check for bladder distention
B.) loosen or remove any tight clothing C.) Monitor stool output and maintain a bowel program E.) monitor urinary output and check for bladder distention
The nurse is giving home care instructions to a patient who will be discharged with a halo device. What does the nurse instruct the patient to avoid? select all that apply A.) going out in the cold B.) swimming or contact sports C.) sexual activity D.) bathing in the bathtub E.) driving
B.) swimming or contact sports E.) driving
The nurse is preparing a quadriplegic patient for discharge and has taught the patient's spouse to assist the patient with a "quad cough" to prevent respiratory complications. Which observation indicates that the spouse has understood what has been taught? A.) the spouse assists the patient to the side of the bed to encourage deep breaths B.) the spouse places her hands below the patient's diaphragm and pushes upward as the patient exhales C.) The spouse places her hands above the patient's diaphragm and pushes upward as the patient inhales D.) The spouse places the patient in an upright sitting position to encourage deep breaths
B.) the spouse places her hands below the patient's diaphragm and pushes upward as the patient exhales
The nurse and the nursing student are working together to bathe and reposition a patient who is in a halo fixator device. Which action by the nursing student causes the supervising nurse to intervene? A.) uses the log-roll technique to clean the patient's back and buttocks B.) turns the patient by pulling on the top of the halo device C.) position the patient with the head and neck in alignment D.) supports the head and neck area during the repositioning
B.) turns the patient by pulling on the top of the halo device
A patient with an SCI has paraplegia and paraparesis. the nurse has identified a priority patient problem of inability to ambulate. the nurse assesses the calf area of both legs for swelling, tenderness, redness or possible complaints of pain. The assessment id specific to the patient's increased risk for which condition? A.) contractures of joints B.) bone fractures C.) pressure ulcers D.) deep vein thrombosis
D.) deep vein thrombosis
The nurse is caring for a patient with a spinal cord injury which is experiencing neurogenic shock. The patient's systolic blood pressure is 88 mm/hg despite starting a dopamine drip 2 hours earlier. There is a new order to infuse 500ml of Dextran-40 over 4 hours. At what rate does the nurse set infusion pump? A.) 75ml/hr B.) 100ml/hr C.) 125ml/hr D.) 150ml/hr
C.) 125ml/hr
A patient has just undergone a laminectomy and returned from surgery at 1300 hours. At 1530 hours, the nurse is performing the change of shift assessment. Which postoperative findings are reported to the surgeon immediately? select all that apply A.) Minimal serosanguineous drainage in the surgical drain B.) Pain at the operative site C.) Swelling or bulging at the operative site D.) Reluctance or refusal to cough and deep-breathe E.) Moderate clear drainage on the postoperative dressing
C.) Swelling or bulging at the operative site E.) Moderate clear drainage on the postoperative dressing
The patient with a spinal cord injury has a heart rate of 42/minute. Which drug does the nurse expect to administer? A.) methylprednisolone B.) dextran C.) atropine D.) dopamine
C.) atropine
The nurse is providing discharge teaching for a patient with a spinal cord injury who will be performing intermittent self-catheterizations at home. Which signs and symptoms will the nurse instruct the patient to report immediately to the primary health care provider? select all that apply A.) dysuria B.) retention C.) fever D.) urgency E.) foul-smelling urine F.) back pain
C.) fever E.) foul-smelling urine
What is a potential adverse outcome of autonomic dysreflexia in a patient with a spinal cord injury? A.) heatstroke B.) paralytic ileus C.) hypertensive stroke D.) aspiration and pneumonia
C.) hypertensive stroke
The patient is an adolescent who is quadriplegic as a result of a diving accident. The nursing assistant reports that the patient started yelling and spitting at her while she was trying to bathe him. He is angry and hostile, stating "nobody is going to do anything else to me! I'm going to get out of this place!" what is the priority patient problem? A.) noncompliance B.) cognitive limitations C.) inability to cope with the situation D.) feelings of hopelessness
C.) inability to cope with the situation
A patient has been talking to his physician about drugs that could potentially be used in the treatment of acute low back pain. Which statement by the patient indicates a need for additional teaching? A.) "The doctor may prescribe an antiseizure drug such as oxcarbazepine; therefore, I would need to have blood tests to check my sodium levels." B.) "The doctor may suggest over the counter ibuprofen; therefore, I should watch for and report dark or tarry stools." C.) "The doctor may prescribe an oral steroid such as prednisone; this would be short-term therapy and the dose would gradually taper off." D.) "The doctor may prescribe hydromorphone and it may cause drowsiness; I should not drive or drink alcohol when I take it."
D.) "The doctor may prescribe hydromorphone and it may cause drowsiness; I should not drive or drink alcohol when I take it."
A patient has had an anterior cervical discectomy with fusion and has returned from the recovery room. What is the priority assessment? A.) Assess for the gag reflex and ability to swallow own secretions B.) check for bleeding and drainage at the incision site C.) Monitor vital signs and check neurologic status D.) Assess for potency of airway and respiratory effort
D.) Assess for potency of airway and respiratory effort
