Nursing Management: Peripheral Nerve and Spinal Cord Problems

In which order will the nurse perform the following actions when caring for a patient with possible C6 spinal cord trauma who is admitted to the emergency department? Put a comma and space between each answer choice (a, b, c, d, etc.) ____________________ a. Infuse normal saline at 150 mL/hr. b. Monitor cardiac rhythm and blood pressure. c. Administer O2 using a non-rebreather mask. d. Transfer the patient to radiology for spinal computed tomography (CT). e. Immobilize the patient's head, neck, and spine.

ANS: E, C, B, A, D The first action should be to prevent further injury by stabilizing the patient's spinal cord. Maintenance of oxygenation by administration of 100% O2 is the second priority. Because neurogenic shock is a possible complication, monitoring of heart rhythm and BP are indicated, followed by infusing normal saline for volume replacement. A CT scan to determine the extent and level of injury is needed once initial assessment and stabilization are accomplished. DIF: Cognitive Level: Application REF: 1553 | 1555 | 1558-1559

The nurse is assessing a patient who is being evaluated for a possible spinal cord tumor. Which finding by the nurse requires the most immediate action? a. The patient has new onset weakness of both legs. b. The patient complains of chronic severe back pain. c. The patient starts to cry and says, "I feel hopeless." d. The patient expresses anxiety about having surgery.

ANS: A The new onset of symptoms indicates cord compression, an emergency that requires rapid treatment to avoid permanent loss of function. The other patient assessments also indicate a need for nursing action but do not require intervention as rapidly as the new onset weakness. DIF: Cognitive Level: Application REF: 1566-1567

When caring for a patient who has Guillain-Barré syndrome, which assessment data obtained by the nurse will require the most immediate action? a. The patient has continuous drooling of saliva. b. The patient's blood pressure (BP) is 106/50 mm Hg. c. The patient's quadriceps and triceps reflexes are absent. d. The patient complains of severe tingling pain in the feet.

ANS: A Drooling indicates decreased ability to swallow, which places the patient at risk for aspiration and requires rapid nursing and collaborative actions such as suctioning and possible endotracheal intubation. The foot pain should be treated with appropriate analgesics, and the BP requires ongoing monitoring, but these actions are not as urgently needed as maintenance of respiratory function. Absence of the reflexes should be documented, but this is a common finding in Guillain-Barré syndrome. DIF: Cognitive Level: Application REF: 1545-1546

When caring for a patient who was admitted 24 hours previously with a C5 spinal cord injury, which nursing action has the highest priority? a. Assessment of respiratory rate and depth b. Continuous cardiac monitoring for bradycardia c. Application of pneumatic compression devices to both legs d. Administration of methylprednisolone (Solu-Medrol) infusion

ANS: A Edema around the area of injury may lead to damage above the C4 level, so the highest priority is assessment of the patient's respiratory function. The other actions also are appropriate but are not as important as assessment of respiratory effort. DIF: Cognitive Level: Application REF: 1550-1551 | 1556-1557 | 1558-1559

A patient with a neck fracture at the C5 level is admitted to the intensive care unit. During initial assessment of the patient, the nurse recognizes the presence of neurogenic shock on finding a. hypotension, bradycardia, and warm extremities. b. involuntary, spastic movements of the arms and legs. c. hyperactive reflex activity below the level of the injury. d. lack of movement or sensation below the level of the injury.

ANS: A Neurogenic shock is characterized by hypotension, bradycardia, and vasodilation leading to warm skin temperature. Spasticity and hyperactive reflexes do not occur at this stage of spinal cord injury. Lack of movement and sensation indicate spinal cord injury, but not neurogenic shock. Cognitive Level: Comprehension REF: 1549-1550

Which action should the nurse take when assessing a patient with trigeminal neuralgia? a. Examine the mouth and teeth thoroughly. b. Have the patient clench and relax the jaw and eyes. c. Identify trigger zones by lightly touching the affected side. d. Gently palpate the face to compare skin temperature bilaterally.

ANS: A Oral hygiene is frequently neglected because of fear of triggering facial pain. Having the patient clench the facial muscles will not be useful because the sensory branches of the nerve are affected by trigeminal neuralgia. Light touch and palpation may be triggers for pain and should be avoided. DIF: Cognitive Level: Application REF: 1542-1543

When teaching patients who are at risk for Bell's palsy because of previous herpes simplex infection, which information should the nurse include? a. "Call the doctor if pain or herpes lesions occur near the ear." b. "Treatment of herpes with antiviral agents prevents Bell's palsy." c. "You may be able to prevent Bell's palsy by doing facial exercises regularly." d. "Medications to treat Bell's palsy work only if started before paralysis onset."

ANS: A Pain or herpes lesions near the ear may indicate the onset of Bell's palsy and rapid corticosteroid treatment may reduce the duration of Bell's palsy symptoms. Antiviral therapy for herpes simplex does not reduce the risk for Bell's palsy. Corticosteroid therapy will be most effective in reducing symptoms if started before paralysis is complete but will still be somewhat effective when started later. Facial exercises do not prevent Bell's palsy. DIF: Cognitive Level: Application REF: 1543-1544

When assessing a patient with newly diagnosed trigeminal neuralgia, the nurse will ask the patient about a. triggers that lead to facial pain. b. visual problems caused by ptosis. c. poor appetite caused by a loss of taste. d. weakness on the affected side of the face.

ANS: A The major clinical manifestation of trigeminal neuralgia is severe facial pain that is triggered by cutaneous stimulation of the nerve. Ptosis, loss of taste, and facial weakness are not characteristics of trigeminal neuralgia. DIF: Cognitive Level: Application REF: 1541-1543

A patient who sustained a spinal cord injury a week ago becomes angry, telling the nurse "I want to be transferred to a hospital where the nurses know what they are doing!" Which reaction by the nurse is best? a. Ask for the patient's input into the plan for care. b. Clarify that abusive behavior will not be tolerated. c. Reassure the patient about the competence of the nursing staff. d. Continue to perform care without responding to the patient's comments.

ANS: A The patient is demonstrating behaviors consistent with the anger phase of the mourning process, and the nurse should allow expression of anger and seek the patient's input into care. Expression of anger is appropriate at this stage and should be tolerated by the nurse. Reassurance about the competency of the staff will not be helpful in responding to the patient's anger. Ignoring the patient's comments will increase the patient's anger and sense of helplessness. DIF: Cognitive Level: Application REF: 1565

A patient with Bell's palsy refuses to eat while others are present because of embarrassment about drooling. The best response by the nurse to the patient's behavior is to a. respect the patient's desire and arrange for privacy at mealtimes. b. teach the patient to chew food on the unaffected side of the mouth. c. offer the patient liquid nutritional supplements at frequent intervals. d. discuss the patient's concerns with visitors who arrive at mealtimes.

ANS: A The patient's desire for privacy should be respected to encourage adequate nutrition and reduce patient embarrassment. Liquid supplements will reduce the patient's enjoyment of the taste of food. It would be inappropriate for the nurse to discuss the patient's embarrassment with visitors unless the patient wishes to share this information. Chewing on the unaffected side of the mouth will enhance nutrition and enjoyment of food but will not decrease the drooling. DIF: Cognitive Level: Application REF: 1543-1545

To evaluate the effectiveness of IV methylprednisolone (Solu-Medrol) given to a patient with a T4 spinal cord injury, which information is most important for the nurse to obtain? a. Leg strength and sensation b. Skin temperature and color c. Blood pressure and apical heart rate d. Respiratory effort and O2 saturation

ANS: A The purpose of methylprednisolone administration is to help preserve motor function and sensation. Therefore the nurse will assess this patient for lower extremity function. The other data also will be collected by the nurse, but they do not reflect the effectiveness of the methylprednisolone. DIF: Cognitive Level: Application REF: 1554-1555

When caring for a patient who experienced a T1 spinal cord transsection 2 days ago, which collaborative and nursing actions will the nurse include in the plan of care (select all that apply)? a. Urinary catheter care b. Nasogastric (NG) tube feeding c. Continuous cardiac monitoring d. Avoidance of cool room temperature e. Administration of H2 receptor blockers

ANS: A, C, D, E The patient is at risk for bradycardia and poikilothermia caused by sympathetic nervous system dysfunction and should have continuous cardiac monitoring and maintenance of a relatively warm room temperature. Gastrointestinal (GI) motility is decreased initially and NG suctioning is indicated. To avoid bladder distention, a urinary retention catheter is used during this acute phase. Stress ulcers are a common complication but can be avoided through the use of the H2 receptor blockers such as famotidine. DIF: Cognitive Level: Application REF: 1555 | 1558-1561

A patient with paraplegia resulting from a T10 spinal cord injury has a neurogenic reflex bladder. Which action will the nurse include in the plan of care? a. Educate on the use of the Credé method. b. Teach the patient how to self-catheterize. c. Catheterize for residual urine after voiding. d. Assist the patient to the toilet every 2 hours.

ANS: B 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. DIF: Cognitive Level: Application REF: 1561-1562

A patient arrives at an urgent care center with a deep puncture wound after stepping on a nail that was lying on the ground. The patient reports having had a tetanus booster 7 years ago. The nurse will anticipate a. IV infusion of tetanus immune globulin (TIG). b. administration of the tetanus-diphtheria (Td) booster. c. intradermal injection of an immune globulin test dose. d. initiation of the tetanus-diphtheria immunization series.

ANS: B If the patient has not been immunized within 5 years, administration of the Td booster is indicated because the wound is deep. Immune globulin administration is given by the IM route if the patient has no previous immunization. Administration of a series of immunization is not indicated. TIG is not indicated for this patient, and a test dose is not needed for immune globulin. DIF: Cognitive Level: Application REF: 1547

A patient with a T1 spinal cord injury is admitted to the intensive care unit. 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.

ANS: B 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. Loss of respiratory function occurs with cervical spine injuries. Bradycardia is associated with injuries above the T6 level. DIF: Cognitive Level: Comprehension REF: 1549-1550

Which action will the nurse include in the plan of care when caring for a patient who is experiencing trigeminal neuralgia? a. Teach facial and jaw relaxation techniques. b. Assess intake and output and dietary intake. c. Apply ice packs for no more than 20 minutes. d. Spend time at the bedside talking with the patient.

ANS: B The patient with an acute episode of trigeminal neuralgia may be unwilling to eat or drink, so assessment of nutritional and hydration status is important. Because stimulation by touch is the precipitating factor for pain, relaxation of the facial muscles will not improve symptoms. Application of ice is likely to precipitate pain. The patient will not want to engage in conversation, which may precipitate attacks. DIF: Cognitive Level: Application REF: 1542-1543

A patient admitted to the emergency department is diagnosed with botulism, and an order for botulinum antitoxin is received. Before administering the antitoxin, it is most important for the nurse to a. obtain the patient's temperature. b. administer an intradermal test dose. c. ask the patient about a history of egg allergies. d. document the presence of neurologic symptoms.

ANS: B To prevent allergic reactions, an intradermal test dose of the antitoxin should be administered. Although temperature, allergy history, and symptom assessment and documentation are appropriate, these assessments will not affect the decision to administer the antitoxin. DIF: Cognitive Level: Application REF: 1546-1547

A 26-year-old patient with a T3 spinal cord injury asks the nurse about whether he will be able to be sexually active. Which initial response by the nurse is best? a. Reflex erections frequently occur, but orgasm may not be possible. b. Sildenafil (Viagra) is used by many patients with spinal cord injury. c. Multiple options are available to maintain sexuality after spinal cord injury. d. Penile injection, prostheses, or vacuum suction devices are possible options.

ANS: C Although sexuality will be changed by the patient's spinal cord injury, there are options for expression of sexuality and for fertility. The other information also is correct, but the choices will depend on the degrees of injury and the patient's individual feelings about sexuality. DIF: Cognitive Level: Application REF: 1563-1564

When evaluating a patient with trigeminal neuralgia who has had a glycerol rhizotomy, the nurse will a. ask whether the patient is using an eye shield at night. b. determine whether the patient is doing daily facial exercises. c. question the patient about social activities with family and friends. d. remind the patient to chew food on the unaffected side of the mouth.

ANS: C Because withdrawal from social activities is a common manifestation of trigeminal neuralgia, asking about social activities will help in evaluating whether the patient's symptoms have improved. Glycerol rhizotomy does not damage the corneal reflex or motor functions of the trigeminal nerve, so there is no need to use an eye shield, do facial exercises, or take precautions with chewing. DIF: Cognitive Level: Application REF: 1542

The health care provider prescribes these interventions for a patient with possible botulism poisoning. Which one will the nurse question? a. Maintain NPO status. b. Obtain lumbar puncture tray. c. Give magnesium citrate 8 oz now. d. Administer 1500-mL tap water enema.

ANS: C Magnesium is contraindicated because it may worsen the neuromuscular blockade. The other orders are appropriate for the patient. DIF: Cognitive Level: Application REF: 1546-1547

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

ANS: C Since the cough effort is poor, 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. 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. DIF: Cognitive Level: Application REF: 1559

A patient with a history of a T2 spinal cord injury 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. Assess for a fecal impaction. b. Give the prescribed antiemetic. c. Check the blood pressure (BP). d. Notify the health care provider.

ANS: C 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 occurring. 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. DIF: Cognitive Level: Application REF: 1556-1557 | 1560-1561

After a 25-year-old patient has returned home following rehabilitation for a spinal cord injury, the home care nurse notes that the spouse is performing many of the activities that the patient had been managing during rehabilitation. The most appropriate action by the nurse at this time is to a. tell the spouse that the patient can perform activities independently. b. remind the patient about the importance of independence in daily activities. c. develop a plan to increase the patient's independence in consultation with the patient and the spouse. d. recognize that it is important for the spouse to be involved in the patient's care and support the spouse's participation.

ANS: C 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 spouse that the patient can perform activities independently is not the best choice. Reminding the patient about the importance of independence may not change the behaviors of the spouse. Supporting the activities of the spouse will lead to ongoing dependency by the patient. DIF: Cognitive Level: Application REF: 1565

A patient has an incomplete right spinal cord lesion at the level of T7, resulting in Brown-Séquard syndrome. Which nursing action should be included in the plan of care? a. Assessment of the patient for left leg pain b. Assessment of the patient for left arm weakness c. Positioning the patient's right leg when turning the patient d. Teaching the patient to look at the left leg to verify its position

ANS: C The patient with Brown-Séquard syndrome has loss of motor function on the ipsilateral side and will require the nurse to move the right leg. Pain sensation will be lost on the patient's left leg. Left arm weakness will not be a problem for a patient with a T7 injury. The patient will retain position sense for the left leg. DIF: Cognitive Level: Application REF: 1550-1551

Which of these nursing actions for a patient with Guillain-Barré syndrome is most appropriate for the nurse to delegate to an experienced nursing assistant? a. Nasogastric tube feeding q4hr b. Artificial tear administration q2hr c. Assessment for bladder distention q2hr d. Passive range of motion to extremities q8hr

ANS: D Assisting a patient with movement is included in nursing assistant education and scope of practice. Administration of tube feedings, administration of ordered medications, and assessment are skills requiring more education and scope of practice, and the RN should perform these skills. DIF: Cognitive Level: Application REF: 1545-1546

A patient who has numbness and weakness of both feet is hospitalized with Guillain-Barré syndrome. The nurse will anticipate the need to teach the patient about a. intubation and mechanical ventilation. b. administration of IV corticosteroid drugs. c. insertion of a nasogastric (NG) feeding tube. d. IV infusion of immunoglobulin (Sandoglobulin).

ANS: D Because the Guillain-Barré syndrome is in the earliest stages (as evidenced by the symptoms), use of high-dose immunoglobulin is appropriate to reduce the extent and length of symptoms. Mechanical ventilation and tube feedings may be used later in the progression of the syndrome but are not needed now. Corticosteroid use is not helpful in reducing the duration or symptoms of the syndrome. DIF: Cognitive Level: Application REF: 1545

Which nursing action will the home health nurse include in the plan of care for a patient with paraplegia in order to prevent autonomic dysreflexia? a. Assist with selection of a high protein diet. b. Use quad coughing to assist cough effort. c. Discuss options for sexuality and fertility. d. Teach the purpose of a prescribed bowel program.

ANS: D Fecal impaction is a common stimulus for autonomic dysreflexia. The other actions may be included in the plan of care but will not reduce the risk for autonomic dysreflexia. DIF: Cognitive Level: Application REF: 1560-1561

A 24-year-old patient is hospitalized with the onset of Guillain-Barré syndrome. During this phase of the patient's illness, the most essential assessment for the nurse to carry out is a. monitoring the cardiac rhythm. b. determining level of consciousness. c. checking strength of the extremities. d. observing respiratory rate and effort.

ANS: D The most serious complication of Guillain-Barré syndrome is respiratory failure, and the nurse should monitor respiratory function continuously. The other assessments also will be included in nursing care, but they are not as important as respiratory assessment. DIF: Cognitive Level: Application REF: 1545

When the nurse is developing a rehabilitation plan for a patient with a C6 spinal cord injury, an appropriate patient goal is that the patient will be able to a. transfer independently to a wheelchair. b. drive a car with powered hand controls. c. turn and reposition independently when in bed. d. push a manual wheelchair on flat, smooth surfaces.

ANS: D The patient with a C6 injury will be able to use the hands to push a wheelchair on flat, smooth surfaces. Because flexion of the thumb and fingers is minimal, the patient will not be able to grasp a wheelchair during transfer, drive a car with powered hand controls, or turn independently in bed. DIF: Cognitive Level: Application REF: 1552