Ch. 43 Flashcards
A nurse promotes the prevention of lower back pain by teaching clients at a community center. Which instruction should the nurse include in this education?
a.
“Participate in an exercise program to strengthen muscles.”
b.
“Purchase a mattress that allows you to adjust the firmness.”
c.
“Wear flat instead of high-heeled shoes to work each day.”
d.
“Keep your weight within 20% of your ideal body weight.”
ANS: A
Exercise can strengthen back muscles, reducing the incidence of low back pain. The other options will not prevent low back pain.
DIF: Applying/Application REF: 886
A nurse plans care for a client with lower back pain from a work-related injury. Which intervention should the nurse include in this client’s plan of care?
a.
Encourage the client to stretch the back by reaching toward the toes.
b.
Massage the affected area with ice twice a day.
c.
Apply a heating pad for 20 minutes at least four times daily.
d.
Advise the client to avoid warm baths or showers.
ANS: C
Heat increases blood flow to the affected area and promotes healing of injured nerves. Stretching and ice will not promote healing, and there is no need to avoid warm baths or showers.
DIF: Understanding/Comprehension REF: 887
A nurse assesses a client who is recovering from a diskectomy 6 hours ago. Which assessment finding should the nurse address first?
a.
Sleepy but arouses to voice
b.
Dry and cracked oral mucosa
c.
Pain present in lower back
d.
Bladder palpated above pubis
ANS: D
A distended bladder may indicate damage to the sacral spinal nerves. The other findings require the nurse to provide care but are not the priority or a complication of the procedure.
DIF: Applying/Application REF: 889
A nurse assesses clients at a community center. Which client is at greatest risk for lower back pain?
a.
A 24-year-old female who is 25 weeks pregnant
b.
A 36-year-old male who uses ergonomic techniques
c.
A 45-year-old male with osteoarthritis
d.
A 53-year-old female who uses a walker
ANS: C
Osteoarthritis causes changes to support structures, increasing the client’s risk for low back pain. The other clients are not at high risk.
DIF: Remembering/Knowledge REF: 886
A nurse teaches a client who is recovering from a spinal fusion. Which statement should the nurse include in this client’s postoperative instructions?
a.
“Only lift items that are 10 pounds or less.”
b.
“Wear your brace whenever you are out of bed.”
c.
“You must remain in bed for 3 weeks after surgery.”
d.
“You are prescribed medications to prevent rejection.”
ANS: B
Clients who undergo spinal fusion are fitted with a brace that they must wear throughout the healing process (usually 3 to 6 months) whenever they are out of bed. The client should not lift anything. The client does not need to remain in bed. Medications for rejection prevention are not necessary for this procedure.
DIF: Applying/Application REF: 888
A nurse assesses a client who is recovering from anterior cervical diskectomy and fusion. Which complication should alert the nurse to urgently communicate with the health care provider?
a.
Auscultated stridor
b.
Weak pedal pulses
c.
Difficulty swallowing
d.
Inability to shrug shoulders
ANS: A
Postoperative swelling can narrow the trachea, cause a partial airway obstruction, and manifest as stridor. The client may also have trouble swallowing, but maintaining an airway takes priority. Weak pedal pulses and an inability to shrug the shoulders are not complications of this surgery.
DIF: Applying/Application REF: 896
A nurse assesses a client with a spinal cord injury at level T5. The client’s blood pressure is 184/95 mm Hg, and the client presents with a flushed face and blurred vision. Which action should the nurse take first?
a.
Initiate oxygen via a nasal cannula.
b.
Place the client in a supine position.
c.
Palpate the bladder for distention.
d.
Administer a prescribed beta blocker.
ANS: C
The client is manifesting symptoms of autonomic dysreflexia. Common causes include bladder distention, tight clothing, increased room temperature, and fecal impaction. If persistent, the client could experience neurologic injury. Precipitating conditions should be eliminated and the physician notified. The other actions would not be appropriate.
DIF: Applying/Application REF: 899
An emergency room nurse initiates care for a client with a cervical spinal cord injury who arrives via emergency medical services. Which action should the nurse take first?
a.
Assess level of consciousness.
b.
Obtain vital signs.
c.
Administer oxygen therapy.
d.
Evaluate respiratory status.
ANS: D
The first priority for a client with a spinal cord injury is assessment of respiratory status and airway patency. Clients with cervical spine injuries are particularly prone to respiratory compromise and may even require intubation. The other assessments should be performed after airway and breathing are assessed.
DIF: Applying/Application REF: 894
An emergency department nurse cares for a client who experienced a spinal cord injury 1 hour ago. Which prescribed medication should the nurse prepare to administer?
a.
Intrathecal baclofen (Lioresal)
b.
Methylprednisolone (Medrol)
c.
Atropine sulfate
d.
Epinephrine (Adrenalin)
ANS: B
Methylprednisolone (Medrol) should be given within 8 hours of the injury. Clients who receive this therapy usually show improvement in motor and sensory function. The other medications are inappropriate for this client.
DIF: Applying/Application REF: 908
A nurse teaches a client with a lower motor neuron lesion who wants to achieve bladder control. Which statement should the nurse include in this client’s teaching?
a.
“Stroke the inner aspect of your thigh to initiate voiding.”
b.
“Use a clean technique for intermittent catheterization.”
c.
“Implement digital anal stimulation when your bladder is full.”
d.
“Tighten your abdominal muscles to stimulate urine flow.”
ANS: D
In clients with lower motor neuron problems such as spinal cord injury, performing a Valsalva maneuver or tightening the abdominal muscles are interventions that can initiate voiding. Stroking the inner aspect of the thigh may initiate voiding in a client who has an upper motor neuron problem. Intermittent catheterization and digital anal stimulation do not initiate voiding or bladder control.
DIF: Applying/Application REF: 900
A nurse is caring for a client with paraplegia who is scheduled to participate in a rehabilitation program. The client states, “I do not understand the need for rehabilitation; the paralysis will not go away and it will not get better.” How should the nurse respond?
a.
“If you don’t want to participate in the rehabilitation program, I’ll let the provider know.”
b.
“Rehabilitation programs have helped many clients with your injury. You should give it a chance.”
c.
“The rehabilitation program will teach you how to maintain the functional ability you have and prevent further disability.”
d.
“When new discoveries are made regarding paraplegia, people in rehabilitation programs will benefit first.”
ANS: C
Participation in rehabilitation programs has many purposes, including prevention of disability, maintenance of functional ability, and restoration of function. The other responses do not meet this client’s needs.
DIF: Applying/Application REF: 900
After teaching a client with a spinal cord injury, the nurse assesses the client’s understanding. Which client statement indicates a correct understanding of how to prevent respiratory problems at home?
a.
“I’ll use my incentive spirometer every 2 hours while I’m awake.”
b.
“I’ll drink thinned fluids to prevent choking.”
c.
“I’ll take cough medicine to prevent excessive coughing.”
d.
“I’ll position myself on my right side so I don’t aspirate.”
ANS: A
Often, the person with a spinal cord injury will have weak intercostal muscles and is at higher risk for developing atelectasis and stasis pneumonia. Using an incentive spirometer every 2 hours helps the client expand the lungs more fully and prevents atelectasis. Clients should drink fluids that they can tolerate; usually thick fluids are easier to tolerate. The client should be encouraged to cough and clear secretions. Clients should be placed in high-Fowler’s position to prevent aspiration.
DIF: Applying/Application REF: 896
A nurse assesses a client with early-onset multiple sclerosis (MS). Which clinical manifestation should the nurse expect to find?
a.
Hyperresponsive reflexes
b.
Excessive somnolence
c.
Nystagmus
d.
Heat intolerance
ANS: C
Early signs and symptoms of MS include changes in motor skills, vision, and sensation. Hyperresponsive reflexes, excessive somnolence, and heat intolerance are later manifestations of MS.
DIF: Understanding/Comprehension REF: 905
A nurse cares for a client who presents with an acute exacerbation of multiple sclerosis (MS). Which prescribed medication should the nurse prepare to administer?
a.
Baclofen (Lioresal)
b.
Interferon beta-1b (Betaseron)
c.
Dantrolene sodium (Dantrium)
d.
Methylprednisolone (Medrol)
ANS: D
Methylprednisolone is the drug of choice for acute exacerbations of the disease. The other drugs are not used to treat acute exacerbations of MS. Interferon beta-1b is used to treat and control MS, decrease specific symptoms, and slow the progression of the disease. Baclofen and dantrolene sodium are prescribed to lessen muscle spasticity associated with MS.
DIF: Applying/Application REF: 908
A nurse assesses a client with multiple sclerosis after administering prescribed fingolimod (Gilenya). For which adverse effect should the nurse monitor?
a.
Peripheral edema
b.
Black tarry stools
c.
Bradycardia
d.
Nausea and vomiting
ANS: C
Fingolimod (Gilenya) is an antineoplastic agent that can cause bradycardia, especially within the first 6 hours after administration. Peripheral edema, black and tarry stools, and nausea and vomiting are not adverse effects of fingolimod.
DIF: Applying/Application REF: 908
