chapter 63

Question 1

The nurse is assessing a client with newly diagnosed trigeminal neuralgia. Which of the following parameters should the nurse assess?
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

Answer 1

a. Triggers that lead to facial pain

Question 2

Which of the following actions should the nurse take when assessing a client with trigeminal neuralgia?
a. Examine the mouth and teeth thoroughly.
b. Have the client 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.

Answer 2

a. Examine the mouth and teeth thoroughly.

Question 3

The nurse is caring for a client with trigeminal neuralgia who has had a glycerol rhizotomy. Which of the following interventions should the nurse implement?
a. Ask whether the client is using an eye shield at night.
b. Determine whether the client is doing daily facial exercises.
c. Question the client about social activities with family and friends.
d. Remind the client to chew food on the unaffected side of the mouth.

Answer 3

c. Question the client about social activities with family and friends.

Question 4

Which of the following actions should the nurse include in the plan of care when caring for a client 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 client.

Answer 4

b. Assess intake and output and dietary intake.

Question 5

The nurse is teaching a client who is at risk for Bell’s palsy because of previous herpes simplex infection. Which of the following 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.”

Answer 5

a. “Call the doctor if pain or herpes lesions occur near the ear.”

Question 6

The nurse is caring for a client with Bell’s palsy who refuses to eat while others are present because of embarrassment about drooling. Which of the following responses is best for the nurse to do?
a. Respect the client’s desire and arrange for privacy at mealtimes.
b. Teach the client to chew food on the unaffected side of the mouth.
c. Offer the client liquid nutritional supplements at frequent intervals.
d. Discuss the client’s concerns with visitors who arrive at mealtimes.

Answer 6

a. Respect the client’s desire and arrange for privacy at mealtimes.

Question 7

Which of the following nursing actions should the home health nurse include in the plan of care for a client 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.

Answer 7

d. Teach the purpose of a prescribed bowel program.

Question 8

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

Answer 8

a. The client has continuous drooling of saliva.

Question 9

The nurse is caring for a client who has numbness and weakness of both feet and who is hospitalized with Guillain-Barré syndrome. Which of the following information should the nurse include in the client’s plan of care?
a. Intubation and mechanical ventilation
b. Administration of IV corticosteroid drugs
c. Insertion of a nasogastric (NG) feeding tube
d. IV infusion of high dose immunoglobulin (IVIG)

Answer 9

d. IV infusion of high dose immunoglobulin (IVIG)

Question 10

A client arrives at an urgent care centre with a deep puncture wound after stepping on a nail that was lying on the ground. The client reports having had a tetanus booster 7 years ago. Which of the following actions should the nurse 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

Answer 10

b. Administration of the tetanus-diphtheria (Td) booster

Question 11

The nurse is caring for a client with a neck fracture at the C5 level in the intensive care unit. During initial assessment of the client, the nurse recognizes the presence of neurogenic shock upon assessing which of the following findings?
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

Answer 11

a. Hypotension, bradycardia, and warm extremities

Question 12

The nurse is caring for a client who has an incomplete right spinal cord lesion at the level of T7, resulting in Brown-Séquard syndrome. Which of the following nursing actions should be included in the plan of care?
a. Assessment of the client for left leg pain
b. Assessment of the client for left arm weakness
c. Positioning the client’s right leg when turning the client
d. Teaching the client to look at the left leg to verify its position

Answer 12

c. Positioning the client’s right leg when turning the client

Question 13

The nurse is caring for a client with a T1 spinal cord injury in the intensive care unit. Which of the following information should the nurse include in the teaching plan for the client and family?
a. Use of the shoulders will be preserved.
b. Full function of the client’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.

Answer 13

b. Full function of the client’s arms will be retained.

Question 14

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

Answer 14

b. Teach the client how to self-catheterize.

Question 15

The nurse is developing a rehabilitation plan for a client with a C6 spinal cord injury. Which of the following goals should the nurse include for this client?
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.

Answer 15

d. Push a manual wheelchair on flat, smooth surfaces.

Question 16

The nurse is caring for a client who sustained a spinal cord injury a week ago and becomes angry, telling the nurse “I want to be transferred to a hospital where the nurses know what they are doing!” Which of the following actions by the nurse is best?
a. Ask for the client’s input into the plan for care.
b. Clarify that abusive behaviour will not be tolerated.
c. Reassure the client about the competence of the nursing staff.
d. Continue to perform care without responding to the client’s comments.

Answer 16

a. Ask for the client’s input into the plan for care.

Question 17

After a young adult client has returned home following rehabilitation for a spinal cord injury, the home care nurse notes that the partner is performing many of the activities that the client had been managing during rehabilitation. Which of the following actions by the
nurse is most appropriate at this time?
a. Tell the partner that the client can perform activities independently.
b. Remind the client about the importance of independence in daily activities.
c. Develop a plan to increase the client’s independence in consultation with the client and the partner.
d. Recognize that it is important for the partner to be involved in the client’s care and support the partner’s participation.

Answer 17

c. Develop a plan to increase the client’s independence in consultation with the client and the partner.

Question 18

The health care provider prescribes these interventions for a client with possible botulism poisoning. Which of the following prescriptions should the nurse question?
a. Maintain NPO status.
b. Obtain lumbar puncture tray.
c. Give magnesium citrate 240 mL stat.
d. Administer 1 500 mL tap water enema.

Answer 18

c. Give magnesium citrate 240 mL stat.

Question 19

The nurse is caring for a client who was admitted 24 hours previously with a C5 spinal cord injury. Which of the following nursing actions 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 infusion

Answer 19

a. Assessment of respiratory rate and depth

Question 20

The nurse is caring for a client who has onset Guillain-Barré syndrome. During this phase of the client’s illness, which of the following parameters is the most important for the nurse to assess?
a. Monitor the cardiac rhythm.
b. Determine level of consciousness.
c. Check strength of the extremities.
d. Observe respiratory rate and effort.

Answer 20

d. Observe respiratory rate and effort.

Question 21

The nurse is caring for a client with a C3 injury who is demonstrating diaphragmatic respirations. Which of the following findings should the nurse expect to assess?
a. Tachypnea
b. Hypertension
c. Hypovolemia
d. Hypoventilation

Answer 21

d. Hypoventilation

Question 22

The nurse is caring for a client who had a C8 spinal cord injury 10 days ago and has a weak cough effort and loose-sounding secretions. Which of the following actions should the nurse implement initially?
a. Suction the client’s oral and pharyngeal airway.
b. Administer oxygen at 7–9 L/minute with a face mask.
c. Place the hands just below the xiphoid process and push upward when the client coughs.
d. Encourage the client to use an incentive spirometer every 2 hours during the day.

Answer 22

c. Place the hands just below the xiphoid process and push upward when the client coughs.

Question 23

The nurse is caring for a client who has halo traction. Which of the following weight amounts should the nurse anticipate will be used with the traction when it is first applied?
a. 2.2 kg
b. 3.3 kg
c. 4.4 kg
d. 5.5 kg

Answer 23

d. 5.5 kg

Question 24

The nurse is caring for a client with a T2 spinal cord injury who tells the nurse, “I feel awful today. My head is throbbing, and I feel sick to my stomach.” Which of the following actions 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.

Answer 24

c. Check the blood pressure (BP).

Question 25

The nurse is facilitating a bladder training program for a client who had a spinal cord injury 2 weeks ago and is stable. Which of the following amounts of daily fluid should the nurse include in the client plan of care to maintain the client on fluid restriction?
a. 600–800 mL
b. 1 000–1 200 mL
c. 1 400–1 600 mL
d. 1 800–2 000 mL

Answer 25

d. 1 800–2 000 mL

Question 26

Which of the following nursing interventions is appropriate for a client with a spinal cord injury who is in the anger phase of adjustment?
a. Use firm kindness.
b. Do not allow fixation on the injury.
c. Use simple diagrams to explain the injury.
d. Give cheerful assistance with the activities of daily living.

Answer 26

b. Do not allow fixation on the injury.

Question 27

The nurse is caring for a young adult client with a T3 spinal cord injury who asks the nurse about whether he will be able to be sexually active. Which of the following initial responses by the nurse is best?
a. Reflex erections frequently occur, but orgasm may not be possible.
b. Sildenafil is used by many clients 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.

Answer 27

c. Multiple options are available to maintain sexuality after spinal cord injury.