Chaps 59 & 63:Neurological Trauma: Head and Spinal Cord Injuries

Question 1

A patient has a systemic blood pressure of 120/60 mm Hg and an intracranial pressure (ICP) of 24 mm Hg. What does the nurse determine that the cerebral perfusion pressure (CPP) of this patient indicates?

a. High blood flow to the brain
b. Normal ICP
c. Impaired blood flow to the brain
d. Adequate autoregulation of cerebral blood flow

Answer 1

ANS: C
The patient’s CPP is 56 mm Hg, below the normal of 70 to 100 mm Hg and approaching the level of ischemia and neuronal death.

Question 2

ICP monitoring is instituted for a patient with a head injury. The patient’s arterial blood pressure is 92/50 mm Hg, and her ICP is 18 mm Hg. Which nursing action is most appropriate?

a. Document and continue to monitor the parameters.
b. Elevate the head of the patient’s bed.
c. Notify the physician about the assessments.
d. Check the patient’s pupillary response to light.

Answer 2

ANS: C
The patient’s CPP is only 46 mm Hg, which will rapidly lead to cerebral ischemia and neuronal death unless rapid action is taken to reduce ICP and increase arterial blood pressure, so the most appropriate action is to contact the physician.

Question 3

Patient manifestations of a headache, CSF leakage, and cranial nerve deficit are signs of which one of the following indications for cranial surgery?

a. Brain tumour
b. Skull fracture
c. Hydrocephalus
d. Intracranial infection

Answer 3

ANS: B
Patient manifestations of a headache, CSF leakage, and cranial nerve deficit indicate a skull fracture, which requires cranial surgery.

Question 4

A patient with a serum sodium level of 115 mmol/L has a decreasing level of consciousness (LOC) and complains of a headache. Which of the following orders should be the priority?

a. Administer acetaminophen (Tylenol) 650 mg orally.
b. Administer 5% hypertonic saline intravenously.
c. Draw blood for arterial blood gases (ABGs).
d. Send the patient to the radiology department for computed tomography of the head.

Answer 4

ANS: B
The patient’s low sodium indicates that hyponatremia may be causing the cerebral edema, and the nurse’s first action should be to correct the low sodium level.

Question 5

The wife of a patient who is in a coma is optimistic about her husband’s recovery because he opens his eyes and appears to be awake. What is the most appropriate response to the wife’s comment?

a. “Your husband’s behaviour is only a reflex and does not really show improvement in his condition.”
b. “Sleep–wake cycles are encouraging signs of recovery, and you should be optimistic about your husband’s condition.”
c. “You are right to be optimistic. When patients begin to recover from a coma, the first behaviours seen are those of wakefulness.”
d. “Your husband may show sleep–wake patterns if the part of the brain responsible for arousal is not injured, but these patterns do not reflect activity of the higher brain centres.”

Answer 5

ANS: D
Arousal is controlled by the reticular activating system in the brainstem and will allow the patient to maintain wakefulness even though the damage to the cerebral cortex is severe.

Question 6

When assessing a patient with a head injury, what will the nurse recognize as an early indication of increased ICP?

a. Vomiting
b. Headache
c. Change in the LOC
d. Sluggish pupillary response to light

Answer 6

ANS: C

LOC is the most sensitive indicator of the patient’s neurological status and possible changes in ICP.

Question 7

A patient is admitted to the hospital with a head injury resulting from an automobile accident. On admission, the patient’s vital signs are temperature 37°C, blood pressure 128/68 mm Hg, pulse 110 beats/min, and respiration 26 breaths/min. One hour after admission, which of the following vital signs does the nurse note indicates the presence of Cushing’s triad?

a. Blood pressure 140/60 mm Hg, pulse 60 beats/min, respiration 14 breaths/min
b. Blood pressure 130/72 mm Hg, pulse 90 beats/min, respiration 24 breaths/min
c. Blood pressure 148/78 mm Hg, pulse 112 beats/min, respiration 28 breaths/min
d. Blood pressure 110/70 mm Hg, pulse 120 beats/min, respiration 30 breaths/min

Answer 7

ANS: A
Systolic hypertension with widening pulse pressure, bradycardia, and respiratory changes represent Cushing’s triad and indicate that the ICP has increased and brain herniation may be imminent unless immediate action is taken to reduce the ICP.

Question 8

Which of the following assessment data of the oculomotor nerve make the nurse suspicious of a possible supratentorial herniation and compression of the brainstem?

a. Absent corneal reflexes
b. Development of nystagmus
c. Right pupil does not react to light
d. Left pupil is 10 mm in size

Answer 8

ANS: C

A dilated pupil on the ipsilateral side in a patient with an acute brain injury indicates herniation.

Question 9

When the nurse applies a painful stimulus to an unconscious patient, the patient responds by stiffly extending and abducting the arms and hyperpronating the wrists. How should the nurse interpret this finding?

a. Decorticate posturing indicating an interruption of voluntary motor tracts
b. Decerebrate posturing indicating an interruption of voluntary motor tracts
c. Decorticate posturing indicating a disruption of motor fibres in the midbrain and brainstem
d. Decerebrate posturing indicating a disruption of motor fibres in the midbrain and brainstem

Answer 9

ANS: D

With decerebrate posturing, the arms are stiffly extended, adducted, and hyperpronated

Question 10

When a patient’s ICP is being monitored with an intraventricular catheter, what is a priority nursing intervention?

a. Maintaining strict aseptic technique to prevent infection
b. Maintaining the patient’s head in a fixed position
c. Continuous monitoring of the ICP waveform
d. Removing CSF to keep pressure at normal levels

Answer 10

ANS: A
Infection is a serious consideration with ICP monitoring, especially with intraventricular catheters; therefore, a priority intervention would be strict aseptic technique at all times.

Question 11

The charge nurse observes a new graduate nurse who is caring for a patient who has had a craniotomy for a brain tumour. Which action by the new graduate requires the charge nurse to intervene and provide additional teaching?

a. The new nurse has the patient breathe deeply and cough.
b. The new nurse assesses neurological status every hour.
c. The new nurse elevates the head of the bed to 30 degrees.
d. The new nurse administers an analgesic before turning the patient.

Answer 11

ANS: A

Coughing can increase ICP and is generally discouraged in patients at risk for increased ICP

Question 12

A patient is brought to the emergency department by ambulance after she was found unconscious on the bathroom floor by her husband. In admitting the patient, what is it most important for the nurse to assess first?

a. Health history
b. Airway patency
c. Neurological status
d. Status of bodily functions

Answer 12

ANS: B

Airway patency and breathing are the most vital functions and should be assessed first.

Question 13

Mechanical ventilation with a rate and volume to maintain a mild hyperventilation is used for a patient with a head injury. Which of the following should the nurse do to evaluate the effectiveness of the therapy?

a. Monitor oxygen saturation.
b. Check ABGs.
c. Monitor ICP.
d. Assess the patient’s breath sounds.

Answer 13

ANS: C
The purpose of hyperventilation for a patient with a head injury is reduction of ICP, and ICP should be monitored to evaluate whether the therapy is effective.

Question 14

The physician prescribes intravenous (IV) mannitol (Osmitrol) for an unconscious patient. What would the nurse expect the therapeutic effect of this drug to result in?

a. Decreased seizure activity
b. Decreased cerebral edema
c. Decreased cerebral metabolism
d. Decreased cerebral inflammation

Answer 14

ANS: B

Mannitol is an osmotic diuretic and will reduce cerebral edema and ICP.

Question 15

A patient with a severe head injury has been maintained on IV fluids of 5% dextrose in water (D5W) at 50 mL/hour for 4 days. The nurse will anticipate the need for which of the following?

a. Continue the D5W to provide the needed glucose for brain function.
b. Decrease the rate of IV infusion to avoid increasing cerebral edema.
c. Insert an enteral feeding tube to provide nutritional replacement.
d. Administer IV 5% albumin to increase serum protein levels.

Answer 15

ANS: C
The patient is in a hypermetabolic and hypercatabolic state, and enteral feedings will provide nutrients for brain function and for healing and immune function. D5W does not provide adequate nutrition to meet patient needs and can lead to lower serum osmolarity and cerebral edema.

Question 16

When assessing a patient with a head injury, which assessment information is of most concern to the nurse?

a. The blood pressure increases from 120/54 to 136/62 mm Hg.
b. The patient is more difficult to arouse.
c. The patient complains of a headache at pain level 5 of a 10-point scale.
d. The patient’s apical pulse is slightly irregular.

Answer 16

ANS: B
The change in the LOC is an indicator of increased ICP and suggests that action by the nurse is needed to prevent complications

Question 17

A patient with a head injury opens his eyes when his name is called, curses when he is stimulated, and does not respond to a verbal command to move but attempts to remove a painful stimulus. How should the nurse record the patient’s Glasgow Coma Scale score?

a. 9
b. 11
c. 13
d. 15

Answer 17

ANS: B

The patient has a score of 3 for eye opening, 3 for best verbal response, and 5 for best motor response.

Question 18

The nurse identifies a nursing diagnosis of ineffective breathing pattern related to loss of central nervous system integrative function for a patient who has post-traumatic brain swelling based on which of the following findings?

a. Apneustic breathing
b. Crackles on inspiration
c. Glasgow Coma Scale score less than 8
d. CPP less than 60 mm Hg

Answer 18

ANS: A
Apneustic breathing is caused by loss of central nervous system integration in the pons and is not effective in maximizing gas exchange

Question 19

A woman is admitted unconscious to the emergency department after striking her head on a boulder while hiking. Her husband and three teenaged children will not leave her side and constantly ask about the treatment being given. What is the best approach to the patient’s family?

a. Call the family’s pastor or spiritual advisor to support them while initial care is given.
b. Refer the family members to the hospital counselling service to deal with their anxiety.
c. Allow the family to stay with the patient, and explain all procedures thoroughly to them.
d. Ask the family to wait in the waiting room until the initial assessment can be completed and care can be started.

Answer 19

ANS: C
The need for information about the diagnosis and care is very high in family members of acutely ill patients, and the nurse should allow the family to observe care and explain the procedures.

Question 20

An unconscious patient has a nursing diagnosis of ineffective tissue perfusion (cerebral) related to cerebral tissue swelling. What is an appropriate nursing intervention for this problem?

a. Elevate the head of the bed 30 degrees.
b. Provide a position of comfort with the knees and hips flexed.
c. Cluster nursing interventions to provide uninterrupted periods of rest.
d. Teach the patient to cough and breathe deeply to prevent the necessity for suctioning.

Answer 20

ANS: A

The patient with increased ICP should be maintained in the head-up position to help reduce ICP.

Question 21

The nurse notes that a patient with a head injury has a clear nasal drainage. What is the most appropriate nursing action for this finding?

a. Obtain a specimen of the fluid for culture and sensitivity.
b. Check the nasal drainage for glucose with a Dextrostix or Tes-Tape.
c. Take the patient’s temperature to determine whether a fever is present.
d. Instruct the patient to blow his nose and then check the nares for inflammation.

Answer 21

ANS: B

If the drainage is CSF leakage from a dural tear, glucose will be present

Question 22

A patient was brought to the emergency department when he became faint and disoriented after being hit in the head with a baseball bat during a company picnic. On admission, he has a headache and cannot remember being hit, but he has no other signs of neurological deficit. What would the nurse expect treatment for the patient to include?

a. Diagnostic testing with magnetic resonance imaging
b. Hospitalization for observation for 24 hours
c. Discharge with observation and monitoring instructions
d. Administration of a narcotic for the headache, followed by observation for several hours

Answer 22

ANS: C
A patient with a minor head trauma is usually discharged with instructions about neurological monitoring and the need to return if neurological status deteriorates.

Question 23

A victim of an automobile accident was found unconscious at the scene of the accident but regained consciousness during transport to the hospital. Shortly after admission, her Glasgow Coma Scale score is 8, and an acute epidural hematoma is suspected. The nurse plans care for the patient based on the expectation that which of the following treatments will be included?

a. Immediate craniotomy
b. Administration of IV furosemide (Lasix)
c. Administration of IV corticosteroids
d. Endotracheal intubation with mechanical ventilation

Answer 23

ANS: A
As the Glasgow Coma Scale indicates a severe head injury, the principal treatment for epidural hematoma is rapid surgery to remove the hematoma and prevent herniation; therefore, an immediate craniotomy is expected

Question 24

The nurse notes clear drainage from the nose of a patient with a frontal skull fracture and recognizes that which of the following interventions is absolutely contraindicated for this patient?

a. Lying flat
b. Eating solid food
c. Inserting a nasogastric tube
d. Cold packs for facial bruising

Answer 24

ANS: C
Rhinorrhea may indicate a dural tear with CSF leakage, and insertion of a nasogastric tube will increase the risk for infections such as meningitis.

Question 25

In planning long-term care for the patient following brain trauma, what is the primary reason the nurse includes teaching and support for the family?

a. Patients will always have some residual deficits of the brain damage.
b. Most patients experience seizure disorders in the weeks or even years following head injury.
c. Families become dysfunctional and unable to cope with the role reversals required during convalescence.
d. Patients with head injuries with unconsciousness often have changes in personality with loss of concentration and memory processing.

Answer 25

ANS: D
Changes in personality, concentration, and memory are common after severe head injury and require anticipatory guidance for the patient and family

Question 26

During the assessment of a patient who has a tumour of the left frontal lobe, what would the nurse expect to find?

a. Speech disturbances
b. Ataxic gait and vertigo
c. Personality and judgement changes
d. Papilledema and vision disturbances

Answer 26

ANS: C

The frontal lobes control intellectual activities such as judgement.

Question 27

A patient with increasing headaches who is having diagnostic testing for a brain tumour asks the nurse what type of treatment will be used if a tumour is discovered. Which response is most appropriate?

a. “If the tumour is benign, treatment may not be necessary.”
b. “Therapy to remove or reduce the tumour size will be recommended.”
c. “Surgery will initially be used to reduce or remove the tumour.”
d. “Chemotherapy is used to shrink the tumour, followed by craniotomy.”

Answer 27

ANS: B

Treatment is designed to reduce tumour size or remove the tumour

Question 28

Which one of the following types of cranial surgery is done to remove a bone flap?

a. Burr hole
b. Craniotomy
c. Craniectomy
d. Cranioplasty

Answer 28

ANS: C

A craniectomy is an excision into the cranium to cut away a bone flap.

Question 29

Which one of the following can be caused by bacteria, fungi, a parasite, or a virus?

a. Meningitis
b. Brain abscess
c. Encephalitis
d. Brain hemorrhage

Answer 29

ANS: C

Encephalitis can be caused by bacteria, fungi, a parasite, or a virus

Question 30

Following a craniotomy with a craniectomy and left anterior fossa incision, the patient has a nursing diagnosis of ineffective protection related to decreased level of consciousness and weakness. What does an appropriate nursing intervention for the patient include?

a. Assessing for changes in motor ability daily
b. Performing range-of-motion exercises every 4 hours
c. Turning and repositioning the patient side to side every 4 hours
d. Eliminating extraneous noise to prevent sensory overload

Answer 30

ANS: B

Range-of-motion exercises will help prevent the complications of immobility.

Question 31

Direct extension from a local infection in which of the following locations can be a primary cause of a brain abscess?

a. Eye
b. Ear
c. Lung
d. Endocardium

Answer 31

ANS: B
Direct extension from a local ear infection can be a primary cause of a brain abscess; others include tooth, mastoid, or sinus infection

Question 32

A patient admitted with bacterial meningitis and a temperature of 38.9°C has orders for all of these collaborative interventions. Which one should the nurse accomplish first?

a. IV ceftizoxime (Cefizox) 1 g now and every 6 hours
b. IV dexamethasone (Decadron) 4 mg now
c. Hypothermia blanket to keep the temperature less than 38.7°C
d. Nasopharyngeal swab for culture and sensitivity

Answer 32

ANS: D
Antibiotic therapy should be instituted rapidly in bacterial meningitis, but cultures must be done before antibiotics are started.

Question 33

The community health nurse is developing a program to decrease the incidence of meningitis in adolescents and young adults. Which nursing action is most important?

a. Emphasize the importance of handwashing to prevent the spread of infection.
b. Immunize adolescents and college freshmen against Neisseria meningitidis.
c. Vaccinate 11- and 12-year-old children against Haemophilus influenzae.
d. Encourage adolescents and young adults to avoid crowded areas in the winter.

Answer 33

ANS: B
The N. meningitidis vaccination is recommended for children ages 11 and 12, unvaccinated teens entering high school, and college/university freshmen.

Question 34

When assessing a patient with newly diagnosed trigeminal neuralgia, the nurse will ask the patient about which of the following?

a. Triggers that lead to facial pain
b. Visual problems caused by ptosis
c. Poor appetite caused by a loss of taste
d. Decreased sensation on the affected side

Answer 34

ANS: A
The major clinical manifestation of trigeminal neuralgia is severe facial pain that is triggered by cutaneous stimulation of the nerve

Question 35

During assessment of the patient with a recurrence of symptoms of trigeminal neuralgia, what should the nurse do?

a. Examine the oral cavity for the state of hygiene.
b. Observe the extent of facial weakness and eye closure.
c. Identify trigger zones by lightly tickling the affected side of the face.
d. Gently palpate the affected side of the face for warmth and swelling.

Answer 35

ANS: A

Oral hygiene is frequently neglected because of fear of triggering facial pain.

Question 36

A patient with a long history of trigeminal neuralgia recently had a glycerol rhizotomy for control of symptoms. During a follow-up visit after the rhizotomy, what finding indicates to the nurse that the patient has made a successful adjustment to the surgical intervention?

a. The patient uses an eye shield to protect the cornea from injury.
b. The patient develops and implements a daily routine of facial exercises.
c. The patient is careful to chew foods on the unaffected side of the mouth.
d. The patient returns to previous interpersonal and social relationships with family and friends.

Answer 36

ANS: D
Because withdrawal from social activities is a common manifestation of trigeminal neuralgia, enjoyment of social activities indicates successful reduction of symptoms and should be included in the plan of care for this patient.

Question 37

When planning care for a patient during an acute episode of trigeminal neuralgia, what is an appropriate intervention to include?

a. Evaluation of hydration and nutrition status
b. Exercise of the muscles of the face and jaw
c. Application of ice packs to the affected area
d. Regular exercise regimen

Answer 37

ANS: A
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

Question 38

When teaching patients who are at risk for Bell’s palsy because of previous herpes simplex infection, which information should the nurse include?

a. “You should call the doctor if pain or herpes lesions occur near the ear.”
b. “Treatment of herpes with antiviral agents will prevent development of Bell’s palsy.”
c. “Medications to treat Bell’s palsy work only if started before paralysis onset.”
d. “You may be able to prevent Bell’s palsy by doing facial exercises regularly.”

Answer 38

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

Question 39

A patient with Bell’s palsy refuses to eat while others are present. What is the best response to the patient’s behaviour?

a. Respect her desire for privacy, and leave her alone while she eats.
b. Provide a liquid diet high in protein and calories, which she can easily swallow.
c. Assure the patient that it does not bother others to observe her while she eats.
d. Teach the patient to chew her food on the unaffected side of the mouth for better control.

Answer 39

ANS: A

The patient’s desire for privacy should be respected to encourage adequate nutrition and reduce patient embarrassment

Question 40

A patient with Guillain-Barré syndrome asks the nurse what has caused the disease. In responding to the patient, what should the nurse explain about Guillain-Barré syndrome?

a. Results from an acute infection and inflammation of the peripheral nerves
b. Is due to an immune reaction that attacks the covering of the peripheral nerves
c. Is caused by destruction of the peripheral nerves after exposure to a viral infection
d. Results from degeneration of the peripheral nerve caused by viral attacks

Answer 40

ANS: B
Guillain-Barré syndrome is believed to result from an immunological reaction that damages the myelin sheath of the peripheral nerves.

Question 41

A 24-year-old patient is hospitalized with the onset of Guillain-Barré syndrome. During this phase of the patient’s illness, what is the most essential assessment for the nurse to carry out?

a. Monitoring the vital signs every 2 hours
b. Determining the patient’s level of consciousness every 2 hours
c. Performing constant evaluation of respiratory function
d. Evaluating sensory and motor function of the extremities

Answer 41

ANS: C
The most serious complication of Guillain-Barré syndrome is respiratory failure, and the nurse should monitor respiratory function continuously

Question 42

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 complains of severe tingling pain in the feet.
b. The patient has continuous drooling of saliva.
c. The patient’s blood pressure is 106/50 mm Hg.
d. The patient’s quadriceps and triceps reflexes are absent.

Answer 42

ANS: B
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.

Question 43

A 45-year-old woman is hospitalized with Guillain-Barré syndrome. What treatment will the nurse explain will most likely be included during the first 2 to 3 weeks of her illness?

a. Hemodialysis
b. Mechanical ventilation
c. Administration of immune globulin (Sandoglobulin)
d. Administration of methylprednisolone (Solu-Medrol)

Answer 43

ANS: C
Because the Guillain-Barré syndrome is in the earliest stages (as evidenced by the symptoms), use of high-dose immune globulin is appropriate to reduce the extent and length of symptoms.

Question 44

A patient admitted to the emergency department is diagnosed with botulism poisoning, and botulinum antitoxin is to be administered. Before administration of the antitoxin, what should the nurse do?

a. Obtain baseline vital signs.
b. Administer an intradermal test dose.
c. Ask the patient about a history of allergies.
d. Document the presence of neurological symptoms.

Answer 44

ANS: B

To prevent allergic reactions, an intradermal test dose of the antitoxin should be administered

Question 45

A patient arrives at an urgent care centre after stepping on a nail that was embedded in some old lumber in a field. The patient reports having had a tetanus booster 7 years ago. What will the nurse anticipate for care?

a. Intravenous (IV) infusion of tetanus immune globulin
b. Initiation of the tetanus–diphtheria (Td) immunization series
c. Intradermal injection of an immune globulin test dose
d. Administration of the Td toxoid booster

Answer 45

ANS: D
If the patient has not been immunized within 5 years, administration of the Td booster is indicated because the wound is deep.

Question 46

A patient with a cervical neck fracture at the C5 level is admitted to the critical care unit following initial treatment in the emergency department. During initial assessment of the patient, the nurse recognizes the presence of spinal shock on finding which of the following data?

a. Hypotension, bradycardia, and warm extremities
b. Involuntary, spastic movements of the arms and legs
c. Flaccid paralysis and lack of sensation below the level of the injury
d. Loss of voluntary motor control but the presence of reflex activity below the level of the injury

Answer 46

ANS: C
Clinical manifestations of spinal shock include decreased reflexes, loss of sensation, and flaccid paralysis below the area of injury.

Question 47

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 nursing intervention should be to do which of the following?

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.

Answer 47

ANS: B
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.

Question 48

A patient with a spinal cord transection at T1 is in spinal shock. While monitoring the patient, the nurse recognizes that alterations in sympathetic nervous system function may cause which of the following reactions?

a. Tachycardia
b. Bladder hyperirritability
c. Fluctuating body temperature
d. Hypermotility of the gastrointestinal system

Answer 48

ANS: C
Temperature control is largely external to the patient because no vasoconstriction, piloerection, or heat loss through perspiration has occurred below the level of injury. The nurse must monitor the environment closely to maintain an appropriate temperature.

Question 49

As a result of a gunshot wound, 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

Answer 49

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

Question 50

The nurse is aware that which one of the following is the most common cause of premature death in a patient with tetraplegia?

a. Diabetes
b. Acute renal failure
c. Pneumonia
d. Hypertension

Answer 50

ANS: C
The most common cause of premature death in a patient with tetraplegia is pneumonia, urinary tract infections, and pressure ulcers, or any combination of them.

Question 51

During the initial phase of care for a patient with spinal cord trauma at C5, why must the nurse give high priority to maintaining respiratory function?

a. At the C5 level, diaphragmatic and intercostal muscle function is lost.
b. Extension of edema above the site of the injury may affect phrenic nerve function.
c. Immobilization of the patient’s spine promotes pooling of respiratory secretions.
d. Without abdominal muscle control, the patient cannot adequately cough to clear the lungs.

Answer 51

ANS: B
Swelling above the trauma site (i.e., C5) may affect phrenic nerve function, thereby interfering with respiratory function.

Question 52

The physician orders administration of IV methylprednisolone for the first 24 hours to a patient who experienced a spinal cord injury 3 hours ago. What will the nurse assess when evaluating the effectiveness of this drug?

a. Blood pressure and heart rate
b. Respiratory effort and O2 saturation
c. Motor and sensory function of the legs
d. Bowel sounds and abdominal distension

Answer 52

ANS: C
The purpose of methylprednisolone administration is to help preserve neurological function; therefore, the nurse will assess this patient for lower extremity function.

Question 53

A patient with a paraplegia resulting from a T10 spinal cord injury has a neurogenic reflex bladder. The nurse consults with the physician regarding bladder management, recommending that which of the following initial treatments should be included?

a. Intermittent catheterization every 4 hours
b. Limiting fluid intake to 1000 mL/day
c. Clamping a Foley catheter and draining it every 2 hours
d. Catheterization for residual urine after each voiding

Answer 53

ANS: A
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.

Question 54

A patient with a T2 spinal cord injury is beginning intensive rehabilitation. One morning as the nurse prepares to assist her to transfer to the wheelchair, the patient tells the nurse that she does not feel like getting up, that she has a throbbing headache, and that she is slightly nauseated. What is it most important that the nurse do?

a. Notify the physician.
b. Check the patient’s blood pressure.
c. Tell her she will feel better if she sits upright in her wheelchair.
d. Do a digital rectal examination for the presence of an impaction.

Answer 54

ANS: B
The blood pressure 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.

Question 55

The nurse discusses long-range goals with a patient with a C6 spinal cord injury. What is an appropriate patient outcome for the patient?

a. Transfers independently to a wheelchair
b. Drives a car with powered hand controls
c. Feeds himself with powered hand splints
d. Pushes a wheelchair on flat, smooth surfaces

Answer 55

ANS: D

The patient with a C6 injury will be able to use the hands to push a wheelchair on flat, smooth surfaces.

Question 56

A patient who sustained a T1 spinal cord injury a week ago refuses to discuss the injury and becomes verbally abusive to the nurses and other staff. The patient demands to be transferred to another hospital, where “they know what they are doing.” What is the best response to the patient’s behaviour?

a. Ask for the patient’s input into the plan for care.
b. Clarify that abusive behaviour will not be tolerated.
c. Reassure the patient that the anger will pass and rehabilitation will then progress.
d. Ignore the patient’s anger and continue to perform needed assessments and care.

Answer 56

ANS: A
The patient is demonstrating behaviours 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

Question 57

A 26-year-old patient with a C8 spinal cord injury tells the nurse that sexual activity has always been very important to him and his wife, and he worries she may leave him if he cannot function sexually. What is the most appropriate response to the patient’s comment?

a. Advise the patient to talk to his wife about his concerns.
b. Tell the patient that alternative methods of obtaining sexual satisfaction could be used.
c. Inform the patient that most patients with upper motor neuron injuries have reflex erections.
d. Suggest that the patient and his wife work with a nurse specially trained in sexual counselling.

Answer 57

ANS: D
Maintenance of sexuality is an important aspect of rehabilitation after spinal cord injury and should be handled by someone with expertise in sexual counselling. Although the patient should discuss these issues with his wife, open communication about this issue may be difficult without the assistance of a counsellor.

Question 58

A young married woman has returned home following extensive rehabilitation for a C8 spinal cord injury. The home health care nurse visits and notices that the patient’s mother and husband are performing many of the activities of daily living that the patient was managing during rehabilitation. What is the most appropriate nursing action at this time?

a. Encourage the patient to perform her own care as she has been taught.
b. Tell the mother and the husband to stop performing care that the patient can do herself.
c. Recognize that it is important for the patient’s family to be involved in her care and support their activities.
d. Include the husband and the mother in developing a plan of care to increase the patient’s independence.

Answer 58

ANS: D

The best action will be to involve all parties in developing an optimal plan of care.

Question 59

Spinal cord injuries occur most frequently in which age group?

a. 1 to 8 years
b. 10 to 15 years
c. 15 to 25 years
d. 35 to 50 years

Answer 59

ANS: C

Spinal cord injuries occur most frequently in 15- to 25-year-old individuals.

Question 60

When assessing a patient’s grade of impairment, the nurse documents that motor function is preserved below the neurological level and more than half of the key muscle functions below the level have a muscle grade of 2. According to the American Spinal Injury Association Impairment Scale, what grade would the nurse document?

a. A
b. B
c. C
d. D

Answer 60

ANS: C
A grade of C is given to a patient whose motor function is preserved below the neurological level and more than half of the key muscle functions below the level have a muscle grade of less than 3.

Question 61

Which of the following would the nurse expect from a patient with a spinal cord injury at the level of C7?

a. The patient is able to stand with long leg braces.
b. The patient is independent in all self-care activities.
c. The patient is independent with transferring from a wheelchair to bed.
d. The patient may require assistance with bowel functioning.

Answer 61

ANS: C
A patient with a spinal cord injury at the level of C7 is independent with most self-care activities, independent with transfers and in a wheelchair.

Question 62

A patient is exhibiting signs of autonomic dysreflexia. Which of the following would the nurse do first?

a. Raise the patient to a sitting position.
b. Check bladder for distension.
c. Assess for tight clothing.
d. Call the health care provider.

Answer 62

ANS: A
Although all of the choices are immediate interventions in the care of a patient with autonomic dysreflexia, the initial intervention is to raise the patient to a sitting position.