Neuro 2

What should the nurse assess for when a client with a cervical injury reports a severe headache and nasal congestion?

1. Suprapubic distension

The nurse is caring for a patient with a spinal cord injury who is experiencing neurogenic shock. The patient has a dopamine drip, but the systolic blood pressure is 88 mmhg. There is a new order to infuse 500 ml of dextran-40 over 4 hours. At what rate does the nurse set the infusion pump?

125 ml/hr

After a traumatic spinal cord severance, a young client is having a difficult accepting the 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?

3. Spinal shock has subsided and the client's reflexes are hyperactive.

The nurse is taking a history on an adult patient who reports acute back pain. Which question is the nurse most likely to ask to identify causative factors?

A. "Have you had a recent fall or accident or lifted a heavy object?"

The nurse reviews the discharge and home care instructions with a patient who had conventional open back surgery. Which statement by the patient indicates further teaching is needed?

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 task is best delegated to unlicensed assistive personnel?

A. Assist the nurse to log roll the patient every 2 hours.

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?

A. Assist with the removal of oral secretions.

`A client with a spinal cord injury has paraplegia. The nurse assess for which major problem the client may experience early in the recovery period?

A. Bladder control

A client with a cervical spinal cord injury has been placed in fixed skeletal traction with a halo fixation device. When caring for this client, the nurse may assign which actions to the LPN/LVN? SATA

A. Checking the clients skin for pressure from the device. C. Observing the halo insertion sites for signs of infection. D. Cleaning the halo insertion sites with hydrogen peroxide. F. Administering oral medications as ordered.

A nurse expects a client with a herniated intervertebral disk to report a sudden increase in pain with which activities? SATA

A. Coughing or sneezing F. Straining when having a bowel movement.

The nurse is caring for a patient who has been in a long-term care facility for several months following a spinal cord injury. The patient has had problems with urinary retention and subsequent overflow incontinence, and a bladder retaining program was recently initiated. What is an expected outcome of the training program?

A. Does not experience a urinary tract infection.

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?

A. Leave the 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 a paraplegic. The family asks the nurse what this means. What explanation should the nurse provide?

A. Lower extremities are paralyzed.

Which clinical indicator does the nurse expect to identify when assessing a client admitted with a herniated lumbar disk?

A. Pain radiating to the hip and leg

The home health nurse reads in the patient's chart that he has spinal cord injury and has developed heterotopic ossification of the right hip. What would the nurse expect to observe while assessing the hip?

A. Redness, warmth, and decreased range of motion.

Which position is therapeutic and comfortable for a patient with acute lower back pain from a herniated disc?

A. Semi-fowler's position with a pillow under the knees to keep them flexed.

The nurse is helping a client with a spinal cord injury to establish a bladder retraining program. Which strategies may stimulate the client to void?

A. Stroking the client's inner thigh B. Pulling on the client's pubic hair D. Pouring warm water over the clients perineum E. Tapping the bladder to stimulate the detrusor muscle

A patient has just undergone a spinal fusion and a laminectomy and has returned from the operating room. Which assessments are done in the first 24 hours? SATA

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 I&O and assess for urinary retention. E. Observe for clear fluid on or around the dressing. F. Assess for and immediately report sudden onset of headache.

A patient is scheduled for lumbar surgery. Which key points must the nurse include in a preoperative teaching plan for this patient? SATA.

A. Techniques for getting in and out of bed. B. Expectations for turning and moving in bed. C. Limitations and restrictions for home activities. E. Immediately report any numbness and tingling. F. Expect difficulties moving affected leg or both legs.

The nurse is caring for a patient who is experiencing spinal shock. What are expected findings that occur with this condition?

A. Temporary loss of motor, sensory, reflex and autonomic functions.

A nurse is in a rehabilitation center teaches clients with quadriplegia to use an adaptive wheelchair. Why is it important that the nurse provide this instruction?

A. They usually will never walk.

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 feels sharp or dull.

A teenager dove head first into a rock quarry pond and is brought the emergency department by emergency medical services. Which questons will the nurse ask the EMS? SATA

A. What were the location and position of the patient immediately after injury? B. Were there problems extricating the patient from the water? D. What symptoms were reported by bystanders and noted en route? E. What changes occured at the scene or en route? F. What treatments were given at the scene or en route?

The nurse is caring for several patients on an orthopedic surgical unit. Which patient has the greatest risk for fat embolism syndrome?

B. 46-year-old who had a spinal fusion for spine stabilization.

Which client should the charge nurse assign to a new graduate RN who is orientating to the neurologic unit?

B. A 67 year old client who had a stroke 3 days ago and has left sided weakness.

Which client should the charge nurse assign to the traveling nurse, new to neurologic nursing care, who has been on the neurologic unit for 1 week?

B. A 68-year-old client with chronic amyotrophic lateral sclerosis.

The nurse is preparing to physically assess a patient's report of paresthesia in the lower extremities. To accomplish this assessment, which assessment technique technique does the nurse use?

B. Ask the patient to identify sharp and dull sensation by using a paper clip and cotton ball.

A patient who was involved in a high speed motor vehicle accident sustained multiple injuries. He is transported to the emergency department by EMS with immobilization devices in place. There is a high probability of cervical spine fracture; the patient has altered mental status and extremities are flaccid. What is the priority assessment for this patient?

B. Assess the respiratory pattern and ensure a patent airway.

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?

B. Assessing for respiratory complications. C. Monitoring and maintaining blood pressure.

A client with a spinal cord injury reports sudden severe throbbing headache that started a short time ago. Assessment of the client reveals increased blood pressure and decreased heart rate, diaphoresis, and flushing of the face and neck. What action should the nurse take first?

B. Check the foley tubing for kinks or obstruction.

The nurse is floated from the emergency department to the neurologic floor. Which action should the nurse delegate to the UAP when providing nursing care for a client with a spinal cord injury?

B. Checking and recording the clients vital signs every 4 hours.

Which patient behavior is most likely to occur with spinal shock?

B. Displays inability or difficulty moving extremities.

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?

B. Driving

The nurse is planning care for a 66 year-old patient with spinal cord injury. Based on the nurse's knowledge of the most likely complication and cause of death for this patient, what would the nurse recommend?

B. Ensure influenza and pneumococcus vaccinations are current.

Which symptoms indicate that a patient with a spinal cord injury is experiencing autonomic dysreflexia? SATA

B. Hypertension D. Severe headache E. blurred vision

The nurse is caring for several patients who have spinal cord injuries. Which task is best to delegate to UAP?

B. Log roll the patient; maintain proper body alignment and place a bedpan for toileting.

The nurse is caring for a patient with a recent spinal cord injury (SCI). Which interventions does the nurse use to target and prevent the potential SCI complication of autonomic dysreflexia? SATA

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. F. Maintain stable environmental temperature.

The patient with chronic back pain is receiving ziconotide by intrathecal (spinal) infusion with a surgically implanted pump. The patient develops hallucinations. What is the nurse's best first action?

B. Notify the health care provider.

Assessment of a patient with a lower spinal cord injury confirms that the patient has paralysis of the bilateral lower extremities. How does the nurse document this finding?

B. Paraplegia

The nurse is assessing a patient who presented to the emergency department reporting acute onset of numbness and tingling in the right leg. How does the nurse document this subjective finding?

B. Paresthesia

A client has paraplegia as a result of a motorcycle accident. What is the reason the nursing care plan should include turning the client every 1-2 hours?

B. Prevent pressure ulcers.

The nurse is assessing a patient with a spinal cord injury that occurred several months ago. The nurse recognizes that the patient is experiencing autonomic dysreflexia. What is the nurse's first priority action?

B. Raise the head of the bed.

What should the nurse include in the plan of care for a client who just had a posterior lumbar laminectomy?

B. 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?

B. Sensory loss in legs.

The nurse is preparing a patient with quadriplegia for discharge and has taught the spouse to assist the patient with a "quad cough" to prevent respiratory complications. Which observation indicates that the spouse has understoond what has been taught?

B. Spouse places her hands below the patient's diaphragm and pushes upward as the patient exhales.

The critical care nurse is assessing a client whose baseline glasgow coma scale score in the emergency department was 5. The current GCS score is 3. What is the nurse's best interpretation of this finding?

B. The client's condition is deteriorating.

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?

B. Turns the patient by grasping the top of the halo device.

The patient with a spinal cord injury has a heart rate of 42/minute. Which drug does the nurse expect to administer?

C. Atropine

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 the immediate phase?

C. Avoiding flexion or hyperextension of the spine.

An adolescent patient has quadriplegia as a result of a diving accident. The UAP 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?

C. Difficulties with situational coping.

The nurse is preparing a nursing care plan for a client with a spinal cord injury for whom problems of decreased mobility and inability to perform activities of daily living have been identified. The client tells the nurse, "I don't know why we're doing all this. My life's over." Based on this statement, which additional nursing concern takes priority?

C. Difficulty with coping.

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? SATA

C. Flaccid paralysis E. Lack of reflexes below the injury

What is a potential adverse outcome of autonomic dysreflexia in a patient with a spinal cord injury?

C. Hypertensive stroke

A patient has just undergone a laminectomy and returned from surgery at 1300 hours. At 1530 hours, the nurse is preforming the change of shift assessment. Which postoperative finding is immediately reported to the surgeon?

C. Swelling or bulging at the operative site.

A patient has been talking to the health care provider 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?

D. "The doctor may prescribe an opioid medication, and it may cause drowsiness; I should not drive or drink alcohol when I take it."

A patient had an anterior cervical discectomy with fusion and has returned from the recovery room. What is the priority assessment?

D. Assess for patency or airway and respiratory effort.

A client with a 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?

D. Limits loss of calcium from the bones.

A nurse should except 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?

D. Proper positioning

What problem is the nurse primarily attempting to prevent when encouraging a client with a spinal cord injury to increase oral fluid intake?

D. Urinary tract infection

A patient with an spinal cord injury has paraplegia and paraparesis. The nurse assesses the calf area of both legs for swelling, tenderness, redness, or pain. This assessment is specific to the patient's increased risk for which condition?

D. Venous thromboembolism

A client with a spinal cord injury at level C3 to C4 is being cared for a by the nurse in the emergency department. What is the priority nursing assessment?

Monitor respiratory effort and oxygen saturation level.