Exam 2 Med3 Flashcards
A patient with a spinal cord injury at the T1 level complains of a severe headache and an “anxious feeling.” Which is the most appropriate initial reaction by the nurse?
- Try to calm the patient and make the environment soothing.
- Assess for a full bladder.
- Notify the healthcare provider.
- Prepare the patient for diagnostic radiography.
- Assess for a full bladder.
Rationale: Autonomic dysreflexia occurs in patients with injury at level T6 or higher, and is a life-threatening situation that will require immediate intervention or the patient will die. The most common cause is an overextended bladder or bowel. Symptoms include hypertension, headache, diaphoresis, bradycardia, visual changes, anxiety, and nausea. A calm, soothing environment is fine, though not what the patient needs in this case. The nurse should recognize this as an emergency and proceed accordingly. Once the assessment has been completed, the findings will need to be communicated to the healthcare provider.
A hospitalized patient with a C7 cord injury begins to yell “I can’t feel my legs anymore.” Which is the most appropriate action by the nurse?
- Remind the patient of her injury and try to comfort her.
- Call the healthcare provider and get an order for radiologic evaluation.
- Prepare the patient for surgery, as her condition is worsening.
- Explain to the patient that this could be a common, temporary problem.
- Explain to the patient that this could be a common, temporary problem.
Rationale: Spinal shock is a condition almost half the people with acute spinal injury experience. It is characterized by a temporary loss of reflex function below level of injury, and includes the following symptomatology: flaccid paralysis of skeletal muscles, loss of sensation below the injury, and possibly bowel and bladder dysfunction and loss of ability to perspire below the injury level. In this case, the nurse should explain to the patient what is happening.
The nurse is caring for a patient with increased intracranial pressure (IICP). The nurse realizes that some nursing actions are contraindicated with IICP. Which nursing action should be avoided?
- Reposition the patient every two hours.
- Position the patient with the head elevated 30 degrees.
- Suction the airway every two hours per standing orders.
- Provide continuous oxygen as ordered.
- Suction the airway every two hours per standing orders.
Rationale: Suctioning further increases intracranial pressure; therefore, suctioning should be done to maintain a patent airway but not as a matter of routine. Maintaining patient comfort by frequent repositioning as well as keeping the head elevated 30 degrees will help to prevent (or even reduce) IICP. Keeping the patient properly oxygenated may also help to control ICP.
A patient with a spinal cord injury (SCI) is admitted to the unit and placed in traction. Which of the following actions is the nurse responsible for when caring for this patient?
Select all that apply.
1. modifying the traction weights as needed
2. assessing the patient’s skin integrity
3. applying the traction upon admission
4. administering pain medication
5. providing passive range of motion
- assessing the patient’s skin integrity
- administering pain medication
- providing passive range of motion
Rationale: The healthcare provider is responsible for initial applying of the traction device. The weights on the traction device must not be changed without the order of a healthcare provider. When caring for a patient in traction, the nurse is responsible for assessment and care of the skin due to the increased risk of skin breakdown. The patient in traction is likely to experience pain and the nurse is responsible for assessing this pain and administering the appropriate analgesic as ordered. Passive range of motion helps prevent contractures; this is often performed by a physical therapist or a nurse.
A patient has manifestations of autonomic dysreflexia. Which of these assessments would indicate a possible cause for this condition? Select all that apply. 1. hypertension 2. kinked catheter tubing 3. respiratory wheezes and stridor 4. diarrhea 5. fecal impaction
- kinked catheter tubing
- fecal impaction
Rationale: Autonomic dysreflexia can be caused by kinked catheter tubing allowing the bladder to become full, triggering massive vasoconstriction below the injury site, producing the manifestations of this process. Acute symptoms of autonomic dysreflexia, including a sustained elevated blood pressure, may indicate fecal impaction. The other answers will not cause autonomic dysreflexia.
An unconscious patient receiving emergency care following an automobile crash accident has a possible spinal cord injury. What guidelines for emergency care will be followed?
Select all that apply.
1. Immobilize the neck using rolled towels or a cervical collar.
2. The patient will be placed in a supine position
3. The patient will be placed on a ventilator.
4. The head of the bed will be elevated.
5. The patient’s head will be secured with a belt or tape secured to the stretcher.
- Immobilize the neck using rolled towels or a cervical collar.
- The patient will be placed in a supine position
- The patient’s head will be secured with a belt or tape secured to the stretcher.
Rationale: In the emergency setting, all patients who have sustained a trauma to the head or spine, or are unconscious should be treated as though they have a spinal cord injury. Immobilizing the neck, maintaining a supine position and securing the patient’s head to prevent movement are all basic guidelines of emergency care. Placement on the ventilator and raising the head of the bed will be considered after admittance to the hospital.
A patient with a spinal cord injury is recovering from spinal shock. The nurse realizes that the patient should not develop a full bladder because what emergency condition can occur if it is not corrected quickly?
- autonomic dysreflexia
- autonomic crisis
- autonomic shutdown
- autonomic failure
- autonomic dysreflexia
Rationale: Be attuned to the prevention of a distended bladder when caring for spinal cord injury (SCI) patients in order to prevent this chain of events that lead to autonomic dysreflexia. Track urinary output carefully. Routine use of bladder scanning can help prevent the occurrence. Other causes of autonomic dysreflexia are impacted stool and skin pressure. Autonomic crisis, autonomic shutdown, and autonomic failure are not terms used to describe common complications of spinal injury associated with bladder distension.
Which patient is at highest risk for a spinal cord injury?
- 18-year-old male with a prior arrest for driving while intoxicated (DWI)
- 20-year-old female with a history of substance abuse
- 50-year-old female with osteoporosis
- 35-year-old male who coaches a soccer team
- 18-year-old male with a prior arrest for driving while intoxicated (DWI)
Rationale: The three major risk factors for spinal cord injuries (SCI) are age (young adults), gender (higher incidence in males), and alcohol or drug abuse. Females tend to engage in less risk-taking behavior than young men.
The nurse understands that when the spinal cord is injured, ischemia results and edema occurs. How should the nurse explain to the patient the reason that the extent of injury cannot be determined for several days to a week?
- “Tissue repair does not begin for 72 hours.”
- “The edema extends the level of injury for two cord segments above and below the affected level.”
- “Neurons need time to regenerate so stating the injury early is not predictive of how the patient progresses.”
- “Necrosis of gray and white matter does not occur until days after the injury.”
- “The edema extends the level of injury for two cord segments above and below the affected level.”
Rationale: Within 24 hours necrosis of both gray and white matter begins if ischemia has been prolonged and the function of nerves passing through the injured area is lost. Because the edema extends above and below the area affected, the extent of injury cannot be determined until after the edema is controlled. Neurons do not regenerate, and the edema is the factor that limits the ability to predict extent of injury.
A patient with a spinal cord injury (SCI) has complete paralysis of the upper extremities and complete paralysis of the lower part of the body. The nurse should use which medical term to adequately describe this in documentation?
- hemiplegia
- paresthesia
- paraplegia
- quadriplegia
- quadriplegia
Rationale: Quadriplegia describes complete paralysis of the upper extremities and complete paralysis of the lower part of the body. Hemiplegia describes paralysis on one side of the body. Paresthesia does not indicate paralysis. Paraplegia is paralysis of the lower body.
Which of the following nursing actions is appropriate for preventing skin breakdown in a patient who has recently undergone a laminectomy?
- Provide the patient with an air mattress.
- Place pillows under patient to help patient turn.
- Teach the patient to grasp the side rail to turn.
- Use the log roll to turn the patient to the side.
- Use the log roll to turn the patient to the side.
Rationale: A patient who has undergone a laminectomy needs to be turned by log rolling to prevent pressure on the area of surgery. An air mattress will help prevent skin breakdown but the patient still needs to be turned frequently. Placing pillows under the patient can help take pressure off of one side but the patient still needs to change positions often. Teaching the patient to grasp the side rail will cause the spine to twist, which needs to be avoided.
The patient is admitted with injuries that were sustained in a fall. During the nurse’s first assessment upon admission, the findings are: blood pressure 90/60 (as compared to 136/66 in the emergency department), flaccid paralysis on the right, absent bowel sounds, zero urine output, and palpation of a distended bladder. These signs are consistent with which of the following?
- paralysis
- spinal shock
- high cervical injury
- temporary hypovolemia
- spinal shock
Rationale: Spinal shock is common in acute spinal cord injuries. In addition to the signs and symptoms mentioned, the additional sign of absence of the cremasteric reflex is associated with spinal shock. Lack of respiratory effort is generally associated with high cervical injury. The findings describe paralysis that would be associated with spinal shock in an spinal injured patient. The likely cause of these findings is not hypovolemia, but rather spinal shock.
While caring for the patient with spinal cord injury (SCI), the nurse elevates the head of the bed, removes compression stockings, and continues to assess vital signs every two to three minutes while searching for the cause in order to prevent loss of consciousness or death. By practicing these interventions, the nurse is avoiding the most dangerous complication of autonomic dysreflexia, which is which of the following?
- hypoxia
- bradycardia
- elevated blood pressure
- tachycardia
- elevated blood pressure
Rationale: Autonomic dysreflexia is an emergency that requires immediate assessment and intervention to prevent complications of extremely high blood pressure. Additional nursing assistance will be needed and a colleague needs to reach the physician stat.
A patient is admitted to the hospital with a CD4 spinal cord injury after a motorcycle collision. The patient’s BP is 83/49, and his pulse is 39 beats/min, and he remains orally intubated. The nurse identifies this pathophysiologic response as caused by
a. increased vasomotor tone after injury
b. a temporary loss of sensation and flaccid paralysis below the level of injury
c. loss of parasympathetic nervous system innervation resulting in vasoconstriction
d. loss of sympathetic nervous system innervation resulting in peripheral vasodilation
D. loss of sympathetic nervous system innervation resulting in peripheral vasodilation
A nurse is caring for a client with a spinal cord injury who reports a severe headache and is sweating profusely. vital signs include BP 220/110, apical heart rate of 54/min. Which of the following acctions should the nurse take first?
a. notify the provider
b. sit the client upright in bed
c. check the client’s urinary catheter for blockage
d. administer antihypertensive medication
B. sit the client upright in bed
Rationale: The greatest risk to the client is experiencing a cerebrovascular accident (stroke) secondary to elevated BP. The first action by the nurse is elevate the head of the bed until the client is in an upright position. this will lower the BP secondary to postural hypotension.
Following a T2 spinal cord injury, the patient develops paralytic ileus. While this condition is present, the nurse anticipates that the patient will need
a. IV fluids
b. tube feedings
c. parenteral nutrition
d. nasogastric suctioning
D. nasogastric suctioning
Rationale: During the first 2 to 3 days after a spinal cord injury, paralytic ileus may occur, and NG suction must be used to remove secretions and gas from the GI tract until peristalsis resumes. IV fluids are used to maintain fluid balance but do not specifically relate to paralytic ileus. Tube feedings would be used only for patients who had difficulty swallowing and not until peristalsis is returned; PN would be used only if the paralytic ileus was unusally prolonged.
An initial incomplete spinal cord injury often results in complete cord damage because of
a. edematous compression of the cord above the level of the injury
b. continued trauma to the cord resulting from damage to stabilizing ligaments
c. infarction and necrosis of the cord caused by edema, hemorrhage, and metabolites
d. mecheanical transection of the cord by sharp vertebral bone fragments after the initial injury
C. infarction and necrosis of the cord caused by edema, hemorrhage, and metabolites
Rationale: The primary injury of the spinal cord rarely affects the entire cord, but the patho of secondary injury may result in damage that is the same as mechanical severance of the cord. Complete cord dissolution occurs through autodestruction of the cord by hemorrhage, edema, and the presence of metabolites and norepinephrine. resulting in anoxia and infarction of the cord. Edema resulting from the inflammatory response may increase the damage as it extends above and below the injury site.
Two days following a spinal cord injury, a patient asks continually about the extent of impairment that will result from the injury. The best response by the nurse is,
a. you will have more normal function when spinal shock resolves and the reflex arc returns
b. the extent of your injury cannot be determined until the secondary injury to the cord is resolved
c. when your condition is more stable, an MRI will be done that can reveal the extent of the cord damage
d. because long-term rehabilitation can affect the return of tunction, it will be years before we can tell when the complete effect will be
B. the extent of your injury cannot be determined until the secondary injury to the cord is resolved
Rationale: Until the edema and necrosis at the site of the injury are resolved in 72 hours to 1 week after the injury, it is not possible to determine how much cord damage is present from the initial injury, how much secondary injury occurred, or how much the cord was damaged by edema that extended above the level of the original injury. The return of reflexes signals only the end of spinal shock, and the reflexes may be inappropriate and excessive, causing spasms that complicate rehab.
A week following a spinal cord injury at T2, a patient experiences movement in his leg and tells the nurse he is recovering some function. The nurses’ best response to the patient is,
a. it is really still too soon to know if you will have a return of function
b. the could be a really positive finding. can you show me the movement
c. that’s wonderful. we will start exercising your legs more frequently now
d. im sorry, but the movement is only a reflex and does not indicate normal function
B. the could be a really positive finding. can you show me the movement
Rationale: in 1 week following a spinal cord injury, there may be a resolution of the edema of the injury and an end to spinal shock. When spinal shock ends, reflex movement and spasms will occur, which may be mistaken for return of function, but with the resolution of edema, some normal function may also occur. it is important when movement occurs to determine whether the movement is voluntary and can be consciously controlled, which would indicate some return of function.
Urinary function during the acute phase of spinal cord injury is maintained with
a. an indwelling catheter
b. intermittent catheterization
c. insertion of a suprapubic catheter
d. use of incontinent pads to protect the skin
A. an indwelling catheterization
A nurse is caring for a client who has a C4 spinal cord injury. which of the following should the nurse recognize the client as being at the greatest risk for?
a. neurogenic shock
b. paralytic ileus
c. stress ulcer
d. respiratory compromise
D. respiratory compromise
Rationale: Using the airway, breathing and circulation priority framework, the greatest risk to the client with a SCI at the level of C4 is respiratory compromise secondary to involvement of the phrenic nerve. Maintenance of an airway and provision of ventilator support as needed is the priority intervention.
During assessment of a patient with a spinal cord injury, the nurse determines that the patient has a poor cough with diaphragmatic breathing. Based on this finding, the nurses’ first action should be to
a. initiate frequent turning and repositioning
b. use tracheal suctioning to remove secretions
c. assess lung sounds and respiratory rate and depth
d. prepare the patient for endotracheal intubation and mechanical ventilation
C. assess lungs sounds and respiratory rate and depth
Rationale: Because pneumonia and atelectasis are potential problems RT ineffective coughing function, the nurse should assess the patient’s breath sound and resp function to determine whether secretions are being retained or whether there is progression of resp impairment. Suctioning is not indicated unless lung sounds indicate retained secretions: position changes will help mobilize secretions. Intubation and mechanical ventilation are used if the patient becomes exhausted from labored breathing or if ABGs deteriorate.
The healthcare provider has ordered IV dopamine (Intropin) for a patient in the emergency deparement with a spinal cord injury. The nurse determines that the drug is having the desired effect when assessment findings include
a. pulse rate of 68
b. respiratory rate of 24
c. BP of 106/82
d. temperature of 96.8
C. BP of 106/82
Rationale: Dopamine is a vasopressor that is used to maintain BP during states of hypotension that occur during neurogenic shock associated with spinal cord injury. Atropine would be used to treat bradycardia. The T reflects some degree of poikilothermism, but this is not treated with medications.
A patient is admitted to the emergency department with a spinal cord injury at the level of T2. Which of the following findings is of most concern to the nurse?
a. SpO2 of 92%
b. HR of 42 beats/min
c. BP of 88/60
d. loss of motor and sensory function in arms and legs
b. HR of 42 beats/min
Rationale: Neurogenic shock associated with cord injuries above the level of T6 greatly decrease the effect of the sympathetic nervous system, and bradycardia and hypotension occur. A heart rate of 42 is not adequate to meet oxygen needs of the body, and while low, the BP is not at a critical point. The O2 sat is ok, and the motor and sensory loss are expected.
Without surgical stabilization, immobilization and traction of the patient with a cervical spinal cord injury most frequently requires the use of
a. kinetic beds
b. hard cervical collars
c. skeletal traction with skull tongs
d. sternal-occipital-mandibular immobilizer (SOMI) brace
C. skeletal traction with skull tongs
Rationale: Cervical injuries usually require skeletal traction with the use of Crutchfield, Vinke, or other types of skull tongs to immobilize the cervical vertebrae, even if fracture has not occurred. Hard cervical collars are used for minor injuries or for stabilization during emergency transport of the patient. Sandbags are also used temporarily to stabilize the neck during insertion of tongs or during diagnostic testing immediately following the injury. Special turning or kinetic beds may be used to turn and mobilize patients who are in cervical traction.
A patient with a spinal cord injury has spinal shock. The nurse plans care for the patient based on the knowledge that
a. rehabilitation measures cannot be initiated until spinal shock has resolved
b. the patient will need continuous monitoring for hypotension, tachycardia, and hypoxemia
c. resolution of spinal shock is manifested by spasticity, hyperreflexia, and reflex emptying of the bladder
d. the patient will have complete loss of motor and sensory functions below the level of the injury, but autonomic functions are not affected
C. c. resolution of spinal shock is manifested by spasticity, hyperreflexia, and reflex emptying of the bladder
Rationale: Spinal shock occurs in about half of all people with acute spinal cord injury. In spinal shock, the entire cord below the level of the lesion fails to function, resulting in a flaccid paralysis and hypomotility of most processes without any reflex activity. Return of reflex activity signals the end of spinal shock. Sympathetic function is impaired belwo the level of the injury because sympathetic nerves leave the spinal cord at the thoracic and lumbar areas, and cranial parasympathetic nerves predominate in control over respirations, heart, and all vessels and organ below the injury. Neurogenic shock results from loss of vascular tone caused by the injury and is manifested by hypotension, peripheral vasodilation, and decreased CO. Rehab activities are not contraindicated during spainl shock and should be instituted if the patient’s cardiopulmonary status is stable.
A patient with a C7 spinal cord injury undergoing rehabilitation tells the nurse he must have the flu because he has a bad headache and nausea. The initial action of the nurse is to
a. call the physician
b. check the patient’s temperature
c. take the patient’s BP
d. elevate the HOB to 90 degrees
c. Take the patient’s BP
One indication for surgical therapy of the patient with a spinal cord injury is when
a. there is incomplete cord lesion involvement
b. the ligaments that support the spine are torn
c. a high cervical injury causes loss of respiratory function
d. evidence of continued compression of the cord is apparent
D. evidence of continued compression of the cord is apparent
Rationale: Although surgical treatment of spinal cord injuries often depends on the preference of the health care provider, surgery is usually indicated when there is continued compression of the cord by extrinsic forces or when there is evidence of cord compression. Other indications may include progressive neurologic deficit, compound fracture of the vertebra, bony fragments, and penetrating wounds of the cord.
A patient is admitted to the emergency department with a possible cervical spinal cord injury following an automobile crash. During the admission of the patient, the nurse places the highest priority on
a. maintaining a patent airway
b. assessing the patient for head and other injuries
c. maintaining immobilization of the cervical spine
d. assessing the patient’s motor and sensory function
a. maintaining a patent airway
Rationale: The need for a patent airway is the first priority for any injured patient, and a high cervical injury may decrease the gag reflex and ability to maintain an airway, as well as the ability to breathe. Maintaining cervical stability is then a consideration, along with assessing for other injuries and the patients neuro status.
A nurse is planning care for a client who suffered a spinal cord injury (SCI) involving a T12 fracture 1 week ago. The client has no muscle control of the lower limbs, bowel, or bladder. which of the following should be the nurses’ greatest priority?
a. prevention of further damage to the spinal cord
b. prevention of contractures of the lower extremities
c. prevention of skin breakdown of areas that lack sensation
d. prevention of postural hypotension when placing the client in a wheelchair
A. prevention of further damage to the spinal cord
Rationale: The greatest risk to the client during the acute phase of a SCI is further damage to the spinal cord. Therefore, when planning care, the priority should be the prevention of further damage to the spinal cord by administration of corticosteroids, minimizing movement of the client until spinal stabilization is accomplished through either traction or surgery, and adequate oxygenation of the client to decrease ischemia of the spinal cord.
Goals of rehabilitation for the patient with an injury at the C6 level include (select all that apply)
a. stand erect with leg brace
b. feed self with hand devices
c. drive an electric wheelchair
d. assist with transfer activities
e. drive adapted van from wheelchair
b. feed self with hand devices
c. drive an electric wheelchair
d. assist with transfer activities
e. drive adapted van from wheelchair
A nurse is caring for a client who experienced a cervical spine injury 3 months ago. Which of the following types of bladder management methods should the nurse use for this client?
a. condom catheter
b. intermittent urinary catheterization
c. crede’s method
d. indwelling urinary catheter
a. condom catheter
Rationale: a client who has a cervical spinal cord injury will also have a upper motor neuron injury, which is manifested by a spastic bladder. because the bladder will empty on its own, a condom catheter is an appropriate method and is noninvasive.
B & C are for flaccid bladder.
A patient is admitted with a spinal cord injury at the C7 level. During assessment the nurse identifies the presence of spinal shock on finding
a. paraplegia with flaccid paralysis
b. tetraplegia with total sensory loss
c. total hemiplegia with sensory and motor loss
d. spastic tetraplegia with loss of pressure sensation
B. tetraplegia with total sensory loss
Rationale: At the C7 level, spinal shock is manifested by tetraplegia and sensory loss. The neurologic loss may be temporary or permanent. Paraplegia with sensory loss would occur at the level of T1. A hemiplegia occurs with central (brain) lesions affecting motor neurons and spastic tetraplegia occurs when spinal shock resolves.
During the patient’s process of grieving for the losses resulting from spinal cord injury, the nurse
a. helps the patient understand that working through the grief will be a lifelong process
b. should assist the patient to move through all stages of the mourning process to acceptance
c. lets the patient know that anger directed at the staff or the family is not a positive coping mechanism
d. facilitates the grieving process so that it is completed by the time the patient is discharged from rehabilitation
A. helps the patient understand that working through the grief will be a lifelong process
In planning community education for prevention of spinal cord injuries, the nurse targets
a. elderly men
b. teenage girls
c. elementary school-age children
d. adolescent and young adult men
D. adolescent and young adult men
Rationale: Spinnal cord injuries are highest in young adult men between the ages of 15 and 30 and those who are impulsive or risk takers in daily living. Other risk factors include alcohol and drug abuse as well as participation in sports and occupational exposure to trauma or violence.
In counseling patient with spinal cord lesions regarding sexual function, the nurse advises a male patient with a complete lower motor neuron lesion that he
a. is most likely to have reflexogenic erections and may experience orgasm if ejaculation occurs
b. may have uncontrolled reflex erections, but that orgasm and ejaculation are usually not possible
c. has a lesion with the greatest possibility of successful psychogenic erection with ejaculation and orgasm
d. will probably be unable to have either psychogenic or reflexogenic erections with no ejaculation or orgasm
D. will probably be unable to have either psychogenic or reflexogenic erections with no ejaculation or orgasm
Rationale: Most patients with a complete lower motor neuron lesion are unable to have either psychogenic or reflexogenic erections, and alterative methods of obtaining sexual satisfaction may be suggested. Patients with incomplete lower motor neuron lesions have the highest possibility of successful psychogenic erections with ejaculation, whereas patients with incomplete upper motor neuron lesions are more likey to experience reflexogeic erections with ejaculation. Patients with complete upper motor neuron lesions usually only have reflex sexual function with rare ejaculation.
A patient with paraplegia has developed an irritable bladder with reflex emptying. The nurse teaches the patient
a. hygiene care for an indwelling urinary catheter
b. how to perform intermittent self-catheterization
c. to empty the bladder with manual pelvic pressure in coordination with reflex voiding patterns
d. that a urinary diversion, such as an ileal conduit, is the easiest way to handle urinary elimination
B. b. how to perform intermittent self-catheterization
Rationale: Intermittent self cath five to six times a day is the recommended method of bladder management for the patient with a spinal cord injury because it more closely mimics normal emptying and has less potential for infectinon. The patient and family should be taught the procedure using clean technique, and if the patient has use of the arms, self-cath is use during the acute phase to prevent overdistention of the bladder and surgical urinary diversions are used if urinary complications occur.
A nurse is caring for a client who experienced a cervical spine injury 24 hours ago. which of the following types of prescribed medications should the nurse clarify with the provider?
a. glucocorticoids
b. plasma expanders
c. H2 antagonists
d. muscle relaxants
D. muscle relaxants
Rationale: The client will still be in spinal shock 24 hours following the injury. the client will not experience muscle spasms until after the spinal shock has resolved, making muscle relaxants unnecessary at this time.
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. Continuous cardiac monitoring for bradycardia
b. Administration of methylprednisolone (Solu-Medrol) infusion
c. Assessment of respiratory rate and depth
d. Application of pneumatic compression devices to both legs
c. Assessment of respiratory rate and depth
Rationale: 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 are also appropriate but are not as important as assessment of respiratory effort.
Cognitive Level: Application Text Reference: p. 1602
Nursing Process: Assessment NCLEX: Physiological Integrity
A 26-year-old patient with a C8 spinal cord injury tells the nurse, “My wife and I have always had a very active sex life, and I am worried that she may leave me if I cannot function sexually.” The most appropriate response by the nurse to the patient’s comment is to
a. advise the patient to talk to his wife to determine how she feels about his sexual function.
b. tell the patient that sildenafil (Viagra) helps to decrease erectile dysfunction in patients with spinal cord injury.
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 counseling.
d. suggest that the patient and his wife work with a nurse specially trained in sexual counseling.
Rationale: Maintenance of sexuality is an important aspect of rehabilitation after spinal cord injury and should be handled by someone with expertise in sexual counseling. Although the patient should discuss these issues with his wife, open communication about this issue may be difficult without the assistance of a counselor. Sildenafil does assist with erectile dysfunction after spinal cord injury, but the patient’s sexuality is not determined solely by the ability to have an erection. Reflex erections are common after upper motor neuron injury, but these erections are uncontrolled and cannot be maintained during coitus.
Cognitive Level: Application Text Reference: p. 1608
Nursing Process: Implementation NCLEX: Psychosocial Integrity
A patient with a neck fracture at the C5 level is admitted to the intensive care unit (ICU) following initial treatment in the emergency room. During initial assessment of the patient, the nurse recognizes the presence of spinal shock on finding
a. hypotension, bradycardia, and warm extremities.
b. involuntary, spastic movements of the arms and legs.
c. the presence of hyperactive reflex activity below the level of the injury.
d. flaccid paralysis and lack of sensation below the level of the injury.
d. flaccid paralysis and lack of sensation below the level of the injury.
Rationale: Clinical manifestations of spinal shock include decreased reflexes, loss of sensation, and flaccid paralysis below the area of injury. Hypotension, bradycardia, and warm extremities are evidence of neurogenic shock. Involuntary spastic movements and hyperactive reflexes are not seen in the patient at this stage of spinal cord injury.
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. Endotracheal suctioning
b. Continuous cardiac monitoring
c. Avoidance of cool room temperature
d. Nasogastric tube feeding
e. Retention catheter care
f. Administration of H2 receptor blockers
b. Continuous cardiac monitoring
c. Avoidance of cool room temperature
d. Nasogastric tube feeding
e. Retention catheter care
f. Administration of H2 receptor blockers
Rationale: 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 distension, a 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.
A patient with a T1 spinal cord injury is admitted to the intensive care unit (ICU). 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.
b. full function of the patient’s arms will be retained.
Rationale: 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. Total loss of respiratory function occurs with injuries above the C4 level and is permanent. Bradycardia is associated with injuries above the T6 level.
In which order will the nurse perform the following actions when caring for a patient with possible cervical spinal cord trauma who is admitted to the emergency department?
a. Administer O2 using a non-rebreathing mask.
b. Monitor cardiac rhythm and blood pressure.
c. Immobilize the patient’s head, neck, and spine.
d. Transfer the patient to radiology for spinal CT.
c. Immobilize the patient’s head, neck, and spine.
a. Administer O2 using a non-rebreathing mask.
b. Monitor cardiac rhythm and blood pressure.
d. Transfer the patient to radiology for spinal CT.
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 intervention by the nurse should be to
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
b. place the hands on the epigastric area and push upward when the patient coughs.
Rationale: 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. Administration of oxygen will improve oxygenation, but the data do not indicate hypoxemia, and oxygen will not help expel respiratory secretions. 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.
The nurse discusses long-range goals with a patient with a C6 spinal cord injury. An appropriate patient outcome is
a. transfers independently to a wheelchair.
b. drives a car with powered hand controls.
c. turns and repositions self independently when in bed.
d. pushes a manual wheelchair on flat, smooth surfaces.
d. pushes a manual wheelchair on flat, smooth surfaces.
Rationale: 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.
A patient with a paraplegia resulting from a T10 spinal cord injury has a neurogenic reflex bladder. When the nurse develops a plan of care for this problem, which nursing action will be most appropriate?
a. Teaching the patient how to self-catheterize
b. Assisting the patient to the toilet q2-3hr
c. Use of the Credé method to empty the bladder
d. Catheterization for residual urine after voiding
a. Teaching the patient how to self-catheterize
Rationale: 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.
Which is most important to respond to in a patient presenting with a T3 spinal injury?
A. Blood pressure of 88/60 mm Hg, pulse of 56 beats/minute
B. Deep tendon reflexes of 1+, muscle strength of 1+
C. Pain rated at 9
D. Warm, dry skin
A. Blood pressure of 88/60 mm Hg, pulse of 56 beats/minute
Neurogenic shock is a loss of vasomotor tone caused by injury, and it is characterized by hypotension and bradycardia. The loss of sympathetic nervous system innervations causes peripheral vasodilation, venous pooling, and a decreased cardiac output. The other options can be expected findings and are not as significant. Patients in neurogenic shock have pink and dry skin, instead of cold and clammy, but this sign is not as important as the vital signs.
The patient arrives in the emergency department from a motor vehicle accident, during which the car ran into a tree. The patient was not wearing a seat belt, and the windshield is shattered. What action is most important for you to do?
A. Determine if the patient lost consciousness.
B. Assess the Glasgow Coma Scale (GCS) score.
C. Obtain a set of vital signs.
D. Use a logroll technique when moving the patient.
D. Use a logroll technique when moving the patient.
When the head hits the windshield with enough force to shatter it, you must assume neck or cervical spine trauma occurred and you need to maintain spinal precautions. This includes moving the patient in alignment as a unit or using a logroll technique during transfers. The other options are important and are done after spinal precautions are applied.
One month after a spinal cord injury, which finding is most important for you to monitor?
A. Bladder scan indicates 100 mL.
B. The left calf is 5 cm larger than the right calf.
C. The heel has a reddened, nonblanchable area.
D. Reflux bowel emptying.
B. The left calf is 5 cm larger than the right calf.
Deep vein thrombosis is a common problem accompanying spinal cord injury during the first 3 months. Pulmonary embolism is one of the leading causes of death. Common signs and symptoms are absent. Assessment includes Doppler examination and measurement of leg girth. The other options are not as urgent to deal with as potential deep vein thrombosis.
Which clinical manifestation do you interpret as representing neurogenic shock in a patient with acute spinal cord injury? A. Bradycardia B. Hypertension C. Neurogenic spasticity D. Bounding pedal pulses
A. Bradycardia
Neurogenic shock results from loss of vasomotor tone caused by injury and is characterized by hypotension and bradycardia. Loss of sympathetic innervation causes peripheral vasodilation, venous pooling, and a decreased cardiac output.
A male client with a spinal cord injury is prone to experiencing automatic dysreflexia. The nurse would avoid which of the following measures to minimize the risk of recurrence?
a. Strict adherence to a bowel retraining program
b. Keeping the linen wrinkle-free under the client
c. Preventing unnecessary pressure on the lower limbs
d. Limiting bladder catheterization to once every 12 hours
d. Limiting bladder catheterization to once every 12 hours
The most frequent cause of autonomic dysreflexia is a distended bladder. Straight catheterization should be done every 4 to 6 hours, and foley catheters should be checked frequently to prevent kinks in the tubing. Constipation and fecal impaction are other causes, so maintaining bowel regularity is important. Other causes include stimulation of the skin from tactile, thermal, or painful stimuli. The nurse administers care to minimize risk in these areas.
A client with a spinal cord injury is prone to experiencing autonomic dysreflexia. The nurse should avoid which measure to minimize the risk of recurrence?
- strict adherence to a bowel retraining program
- keeping the linen wrinkle free under the client
- avoiding unnecessary pressure on the lower limbs
- limiting bladder catheterization to once every 12 hours
- limiting bladder cath to once q12h
(the most frequent cause of autonomic dysreflexia is a distended bladder . Straight cath should be performed q4-6 hrs and foley cath should be checked frequently for kinks in tubing . Constipation and fecal impaction are other causes, so maintaining bowel irregularity is important .
Which type of headache is suspected when the headaches are unilateral and throbbing, preceded by a prodrome of photophobia, and associated with a family history of this type of headache?
a. Cluster
b. Migraine
c. Frontal-type
d. Tension-type
b. Migraine
Migraine headaches are frequently unilateral and usually throbbing. They may be preceded by a prodrome and frequently there is a family history. Cluster headaches are also unilateral with severe bone-crushing pain but there is no prodrome or family history. Frontal-type headache is not a functional type of headache. Tension-type headaches are bilateral with constant, squeezing tightness without prodrome or family history.
A patient is diagnosed with cluster headaches. The nurse knows that which characteristics are associated with this type of headache (select all that apply)?
a. Family history
b. Alcohol is the only dietary trigger
c. Abrupt onset lasting 5 to 180 minutes
d. Severe, sharp, penetrating head pain
e. Bilateral pressure or tightness sensation
f. May be accompanied by unilateral ptosis or lacrimation
b. Alcohol is the only dietary trigger
c. Abrupt onset lasting 5 to 180 minutes
d. Severe, sharp, penetrating head pain
f. May be accompanied by unilateral ptosis or lacrimation
Cluster headaches have only alcohol as a dietary trigger and have an abrupt onset lasting 5 minutes to 3 hours with severe, sharp, penetrating pain. Cluster headaches may be accompanied by unilateral ptosis, lacrimation, rhinitis, facial flushing or pallor and commonly recur several times each day for several weeks, with months or years between clustered attacks. Family history and nausea, vomiting, or irritability may be seen with migraine headaches. Bilateral pressure occurring between migraine headaches and intermittent occurrence over long periods of time are characteristics of tension-type headaches.
What is the most important method of diagnosing functional headaches?
a. CT scan
b. Electromyography (EMG)
c. Cerebral blood flow studies
d. Thorough history of the headache
d. Thorough history of the headache
The primary way to diagnose and differentiate between headaches is with a careful history of the headaches, requiring assessment of specific details related to the headache. Electromyelography (EMG) may reveal contraction of the neck, scalp, or facial muscles in tensiontype headaches but this is not seen in all patients. CT scans and cerebral angiography are used to rule out organic causes of the headaches.
What drug therapy is included for acute migraine and cluster headaches that appears to alter the pathophysiologic process for these headaches?
a. β-Adrenergic blockers such as propranolol (Inderal)
b. Serotonin antagonists such as methysergide (Sansert)
c. Tricyclic antidepressants such as amitriptyline (Elavil)
d. Specific serotonin receptor agonists such as sumatriptan (Imitrex)
d. Specific serotonin receptor agonists such as sumatriptan (Imitrex)
Triptans (sumatriptan [Imitrex]) affect selected serotonin receptors that decrease neurogenic inflammation of the cerebral blood vessels and produce vasoconstriction. Both migraine headaches and cluster headaches appear to be related to vasodilation of cranial vessels and drugs that cause vasoconstriction are useful in treatment of migraine and cluster headaches. Methysergide blocks serotonin receptors in the central and peripheral nervous systems and is used for prevention of migraine and cluster headaches. β adrenergic blockers and tricyclic antidepressants are used prophylactically for migraine headaches but are not effective for cluster headaches.
What is a nursing intervention that is appropriate for the patient with a nursing diagnosis of anxiety related to lack of knowledge of the etiology and treatment of headache?
a. Help the patient to examine lifestyle patterns and precipitating factors.
b. Administer medications as ordered to relieve pain and promote relaxation.
c. Provide a quiet, dimly lit environment to reduce stimuli that increase muscle tension and anxiety.
d. Support the patient’s use of counseling or psychotherapy to enhance conflict resolution and stress reduction.
a. Help the patient to examine lifestyle patterns and precipitating factors.
When the anxiety is related to a lack of knowledge about the etiology and treatment of a headache, helping the patient to identify stressful lifestyle patterns and other precipitating factors and ways of avoiding them are appropriate nursing interventions for the anxiety. Interventions that teach alternative therapies to supplement drug therapy also give the patient some control over pain and are appropriate teaching regarding treatment of the headache. The other interventions may help to reduce anxiety generally but they do not address the etiologic factor of the anxiety.
The nurse is preparing to admit a newly diagnosed patient experiencing tonic-clonic seizures. What could the nurse delegate to unlicensed assistive personnel (UAP)?
a. Complete the admission assessment.
b. Explain the call system to the patient.
c. Obtain the suction equipment from the supply cabinet.
d. Place a padded tongue blade on the wall above the patient’s bed.
c. Obtain the suction equipment from the supply cabinet.
The unlicensed assistive personnel (UAP) is able to
obtain equipment from the supply cabinet or department. The RN may need to provide a list of necessary equipment and should set up the equipment and ensure proper functioning. The RN is responsible for the initial history and assessment as well as teaching the patient about the room’s call system. Padded tongue blades are no longer used and no effort should be made to place anything in the patient’s mouth during a seizure.
How do generalized seizures differ from focal seizures?
a. Focal seizures are confined to one side of the brain and remain focal in nature.
b. Generalized seizures result in loss of consciousness whereas focal seizures do not.
c. Generalized seizures result in temporary residual deficits during the postictal phase.
d. Generalized seizures have bilateral synchronous epileptic discharges affecting the whole brain at onset of the seizure.
d. Generalized seizures have bilateral synchronous epileptic discharges affecting the whole brain at onset of the seizure.
Generalized seizures have bilateral synchronous epileptic discharge affecting the entire brain at onset of the seizure. Loss of consciousness is also characteristic but many focal seizures also include an altered consciousness. Focal seizures begin in one side of the brain but may spread to involve the entire brain. Focal seizures that start with a local focus and spread to the entire brain, causing a secondary generalized seizure, are associated with a transient residual neurologic deficit postictally known as Todd’s paralysis.
Which type of seizure occurs in children, is also known as a petit mal seizure, and consists of a staring spell that lasts for a few seconds?
a. Atonic
b. Simple focal
c. Typical absence
d. Atypical absence
c. Typical absence
The typical absence seizure is also known as petit mal
and the child has staring spells that last for a few seconds. Atonic seizures occur when the patient falls from loss of muscle tone accompanied by brief unconsciousness. Simple focal seizures have focal motor, sensory, or autonomic symptoms related to the area of the brain involved without loss of consciousness. Staring spells in atypical absence seizures last longer than those in typical absence seizures and are accompanied by peculiar behavior during the seizure or confusion after the seizure.
The patient is diagnosed with complex focal seizures. Which characteristics are related to complex focal seizures (select all that apply)?
a. Formerly known as grand mal seizure
b. Often accompanied by incontinence or tongue or cheek biting
c. Psychomotor seizures with repetitive behaviors and lip smacking
d. Altered memory, sexual sensations, and distortions of visual or auditory sensations
e. Loss of consciousness and stiffening of the body with subsequent jerking of extremities
f. Often involves behavioral, emotional, and cognitive functions with altered consciousness
c. Psychomotor seizures with repetitive behaviors and lip smacking
d. Altered memory, sexual sensations, and distortions of visual or auditory
f. Often involves behavioral, emotional, and cognitive functions with altered consciousness
Complex focal seizures are psychomotor seizures with automatisms such as lip smacking. They cause altered consciousness or loss of consciousness producing a dreamlike state and may involve behavioral, emotional, or cognitive experiences without memory of what was done during the seizure. In generalized tonic-clonic seizures (previously known as grand mal seizures) there is loss of consciousness and stiffening of the body with subsequent jerking of extremities. Incontinence or tongue or cheek biting may also occur.
Which type of seizure is most likely to cause death for the patient?
a. Subclinical seizures
b. Myoclonic seizures
c. Psychogenic seizures
d. Tonic-clonic status epilepticus
d. Tonic-clonic status epilepticus
Tonic-clonic status epilepticus is most dangerous because the continuous seizing can cause respiratory insufficiency, hypoxemia, cardiac dysrhythmia, hyperthermia, and systemic acidosis, which can all be fatal. Subclinical seizures may occur in a patient who is sedated, so there is no physical movement. Myoclonic seizures may occur in clusters and have a sudden, excessive jerk of the body that may hurl the person to the ground. Psychogenic seizures are psychiatric in origin and diagnosed with videoelectroencephalography (EEG) monitoring. They occur in patients with a history of emotional abuse or a specific traumatic episode.
A patient admitted to the hospital following a generalized tonic-clonic seizure asks the nurse what caused the seizure. What is the best response by the nurse?
a. “So many factors can cause epilepsy that it is impossible to say what caused your seizure.”
b. “Epilepsy is an inherited disorder. Does anyone else in your family have a seizure disorder?”
c. “In seizures, some type of trigger causes sudden, abnormal bursts of electrical brain activity.”
d. “Scar tissue in the brain alters the chemical balance, creating uncontrolled electrical discharges.”
c. “In seizures, some type of trigger causes sudden, abnormal bursts of electrical brain activity.”
A seizure is a paroxysmal, uncontrolled discharge of neurons in the brain, which interrupts normal function, but the factor that causes the abnormal firing is not clear. Seizures may be precipitated by many factors and although scar tissue may make the brain neurons more likely to fire, it is not the usual cause of seizures. Epilepsy is established only by a pattern of spontaneous, recurring seizures.
A patient with a seizure disorder is being evaluated for surgical treatment of the seizures. The nurse recognizes that what is one of the requirements for surgical treatment?
a. Identification of scar tissue that is able to be removed
b. An adequate trial of drug therapy that had unsatisfactory results
c. Development of toxic syndromes from long-term use of antiseizure drugs
d. The presence of symptoms of cerebral degeneration from repeated seizures
b. An adequate trial of drug therapy that had unsatisfactory results
Most patients with seizure disorders maintain seizure control with medications but if surgery is considered, three requirements must be met: the diagnosis of epilepsy must be confirmed, there must have been an adequate trial with drug therapy without satisfactory results, and the electroclinical syndrome must be defined. The focal point must be localized but the presence of scar tissue is not required.
The nurse teaches the patient taking antiseizure drugs that this method is most commonly used to measure compliance and monitor for toxicity.
a. A daily seizure log
b. Urine testing for drug levels
c. Blood testing for drug levels
d. Monthly electroencephalography (EEG)
c. Blood testing for drug levels
Serum levels of antiseizure drugs are monitored regularly to maintain therapeutic levels of the drug, above which patients are likely to experience toxic effects and below which seizures are likely to occur. Many newer drugs do not require drug level monitoring because of large therapeutic ranges. A daily seizure log and urine testing for drug levels will not measure compliance or monitor for toxicity. EEGs have limited value in diagnosis of seizures and even less value in monitoring seizure control.
Priority Decision: When teaching a patient with a seizure disorder about the medication regimen, what is it most important for the nurse to emphasize?
a. The patient should increase the dosage of the medication if stress is increased.
b. Most over-the-counter and prescription drugs are safe to take with antiseizure drugs.
c. Stopping the medication abruptly may increase the intensity and frequency of seizures.
d. If gingival hypertrophy occurs, the drug should be stopped and the health care provider notified.
c. Stopping the medication abruptly may increase the intensity and frequency of seizures.
If antiseizure drugs are discontinued abruptly, seizures can be precipitated. Missed doses should be made up if the omission is remembered within 24 hours and patients should not adjust medications without professional guidance because this also can increase seizure frequency and may cause status epilepticus. Antiseizure drugs have numerous interactions with other drugs and the use of other medications should be evaluated by health professionals. If side effects occur, the physician should be notified and drug regimens evaluated.
Priority Decision: The nurse finds a patient in bed having a generalized tonic-clonic seizure. During the seizure activity, what actions should the nurse take (select all that apply)?
a. Loosen restrictive clothing.
b. Turn the patient to the side.
c. Protect the patient’s head from injury.
d. Place a padded tongue blade between the patient’s teeth.
e. Restrain the patient’s extremities to prevent soft tissue and bone injury.
a. Loosen restrictive clothing.
b. Turn the patient to the side.
c. Protect the patient’s head from injury.
The focus is on maintaining a patent airway and
preventing patient injury. The nurse should not place objects in the patient’s mouth or restrain the patient.
Following a generalized tonic-clonic seizure, the patient is tired and sleepy. What care should the nurse provide?
a. Suction the patient before allowing him to rest.
b. Allow the patient to sleep as long as he feels sleepy.
c. Stimulate the patient to increase his level of consciousness.
d. Check the patient’s level of consciousness every 15 minutes for an hour.
b. Allow the patient to sleep as long as he feels sleepy.
In the postictal phase of generalized tonic-clonic seizures, patients are usually very tired and may sleep for several hours and the nurse should allow the patient to sleep as long as necessary. Suctioning is performed only if needed and decreased level of consciousness is not a problem postictally unless a head injury has occurred during the seizure.
During the diagnosis and long-term management of a seizure disorder, what should the nurse recognize as one of the major needs of the patient?
a. Managing the complicated drug regimen of seizure control
b. Coping with the effects of negative social attitudes toward epilepsy
c. Adjusting to the very restricted lifestyle required by a diagnosis of epilepsy
d. Learning to minimize the effect of the condition in order to obtain employment
b. Coping with the effects of negative social attitudes toward epilepsy
One of the most common complications of a seizure disorder is the effect it has on the patient’s lifestyle. This is because of the social stigma attached to seizures, which causes patients to hide their diagnosis and to prefer not to be identified as having epilepsy. Medication regimens usually require only once- or twice-daily dosing and the major restrictions of lifestyle usually involve driving and high-risk environments. Job discrimination against the handicapped is prevented by federal and state laws and patients only need to identify their disease in case of medical emergencies.
A patient at the clinic for a routine health examination mentions that she is exhausted because her legs bother her so much at night that she cannot sleep. The nurse questions the patient further about her leg symptoms with what knowledge about restless legs syndrome?
a. The condition can be readily diagnosed with EMG.
b. Other more serious nervous system dysfunctions may be present.
c. Dopaminergic agents are often effective in managing the symptoms.
d. Symptoms can be controlled by vigorous exercise of the legs during the day.
c. Dopaminergic agents are often effective in managing the symptoms.
Restless legs syndrome that is not related to other pathologic processes, such as diabetes mellitus or rheumatic disorders, may be caused by a dysfunction in the basal ganglia circuits that use the neurotransmitter dopamine, which controls movements. Dopamine precursors and dopamine agonists, such as those used for parkinsonism, are effective in managing sensory and motor symptoms. Polysomnography studies during sleep are the only tests that have diagnostic value and although exercise should be encouraged, excessive leg exercise does not have an effect on the symptoms.
Which chronic neurologic disorder involves a deficiency of the neurotransmitters acetylcholine and γ aminobutyric acid (GABA) in the basal ganglia and extrapyramidal system?
a. Myasthenia gravis
b. Parkinson’s disease
c. Huntington’s disease
d. Amyotrophic lateral sclerosis (ALS)
c. Huntington’s disease
Huntington’s disease (HD) involves deficiency of
acetylcholine and γ-aminobutyric acid (GABA) in the basal ganglia and extrapyramidal system that causes the opposite symptoms of parkinsonism. Myasthenia gravis involves autoimmune antibody destruction of cholinergic receptors at the neuromuscular junction. Amyotrophic lateral sclerosis (ALS) involves degeneration of motor neurons in the brainstem and spinal cord.
A 38-year-old woman has newly diagnosed multiple sclerosis (MS) and asks the nurse what is going to happen to her. What is the best response by the nurse?
a. “You will have either periods of attacks and remissions or progression of nerve damage over time.”
b. “You need to plan for a continuous loss of movement, sensory functions, and mental capabilities.”
c. “You will most likely have a steady course of chronic progressive nerve damage that will change your
personality.”
d. “It is common for people with MS to have an acute attack of weakness and then not to have any other symptoms
for years.”
a. “You will have either periods of attacks and remissions or progression of nerve damage over time.”
Most patients with multiple sclerosis (MS) have
remissions and exacerbations of neurologic dysfunction or a relapsing-remitting initial course followed by progression with or without occasional relapses, minor remissions, and plateaus that progressively cause loss of motor, sensory, and cerebellar functions. Intellectual function generally remains intact but patients may experience anger, depression, or euphoria. A few people have chronic progressive deterioration and some may experience only occasional and mild symptoms for several years after onset.
During assessment of a patient admitted to the hospital with an acute exacerbation of MS, what should the nurse expect to find?
a. Tremors, dysphasia, and ptosis
b. Bowel and bladder incontinence and loss of memory
c. Motor impairment, visual disturbances, and paresthesias
d. Excessive involuntary movements, hearing loss, and ataxia
c. Motor impairment, visual disturbances, and paresthesias
Specific neurologic dysfunction of MS is caused by
destruction of myelin and replacement with glial scar tissue at specific areas in the nervous system. Motor, sensory, cerebellar, and emotional dysfunctions, including paresthesias as well as patchy blindness, blurred vision, pain radiating along the dermatome of the nerve, ataxia, and severe fatigue, are the most common manifestations of MS. Constipation and bladder dysfunctions, short-term memory loss, sexual dysfunction, anger, and depression or euphoria may also occur. Excessive involuntary movements and tremors are not seen in MS.
The nurse explains to a patient newly diagnosed with MS that the diagnosis is made primarily by
a. spinal x-ray findings.
b. T-cell analysis of the blood.
c. analysis of cerebrospinal fluid.
d. history and clinical manifestations.
d. history and clinical manifestations.
There is no specific diagnostic test for MS. A diagnosis is made primarily by history and clinical manifestations. Certain diagnostic tests may be used to help establish a diagnosis of MS. Positive findings on MRI include evidence of at least two inflammatory demyelinating lesions in at least two different locations within the central nervous system (CNS). Cerebrospinal fluid (CSF) may have increased immunoglobulin G and the presence of oligoclonal banding. Evoked potential responses are often delayed in persons with MS.
Mitoxantrone (Novantrone) is being considered as treatment for a patient with progressive-relapsing MS. The nurse explains that a disadvantage of this drug compared with other drugs used for MS is what?
a. It must be given subcutaneously every day.
b. It has a lifetime dose limit because of cardiac toxicity.
c. It is an anticholinergic agent that causes urinary incontinence.
d. It is an immunosuppressant agent that increases the risk for infection.
b. It has a lifetime dose limit because of cardiac toxicity.
Mitoxantrone (Novantrone) cannot be used for more than 2 to 3 years because it is an antineoplastic drug that causes cardiac toxicity, leukemia, and infertility. It is a monoclonal antibody given IV monthly when patients have inadequate responses to other drugs. It increases the risk of progressive multifocal leukoencephalopathy.
A patient with MS has a nursing diagnosis of self-care deficit related to muscle spasticity and neuromuscular deficits. In providing care for the patient, what is most important for the nurse to do?
a. Teach the family members how to care adequately for the patient’s needs.
b. Encourage the patient to maintain social interactions to prevent social isolation.
c. Promote the use of assistive devices so the patient can participate in self-care activities.
d. Perform all activities of daily living (ADLs) for the patient to conserve the patient’s energy.
c. Promote the use of assistive devices so the patient can participate in self-care activities.
The main goal in care of the patient with MS is to keep the patient active and maximally functional and promote self-care as much as possible to maintain independence. Assistive devices encourage independence while preserving the patient’s energy. No care activity that the patient can do for himself or herself should be performed by others. Involvement of the family in the patient’s care and maintenance of social interactions are also important but are not the priority in care.
A patient with newly diagnosed MS has been hospitalized for evaluation and initial treatment of the disease. Following discharge teaching, the nurse realizes that additional instruction is needed when the patient says what?
a. “It is important for me to avoid exposure to people with upper respiratory infections.”
b. “When I begin to feel better, I should stop taking the prednisone to prevent side effects.”
c. “I plan to use vitamin supplements and a high-protein diet to help manage my condition.”
d. “I must plan with my family how we are going to manage my care if I become more incapacitated.”
b. “When I begin to feel better, I should stop taking the prednisone to prevent side effects.”
Corticosteroids used in treating acute exacerbations of MS should not be abruptly stopped by the patient because adrenal insufficiency may result and prescribed tapering doses should be followed. Infections may exacerbate symptoms and should be avoided and high-protein diets with vitamin supplements are advocated. Long-term planning for increasing disability is also important.
The classic triad of manifestations associated with Parkinson’s disease is tremor, rigidity, and bradykinesia. What is a consequence related to rigidity?
a. Shuffling gait
b. Impaired handwriting
c. Lack of postural stability
d. Muscle soreness and pain
d. Muscle soreness and pain
The degeneration of dopamine-producing neurons in the substantia nigra of midbrain and basal ganglia lead to this triad of signs. Muscle soreness, pain, and slowness of movement are patient function consequences related to rigidity. Shuffling gait, lack of postural stability, absent arm swing while walking, absent blinking, masked facial expression, and difficulty initiating movement are all related to bradykinesia. Impaired handwriting and hand activities are related to the tremor of Parkinson’s disease (PD).
A patient with a tremor is being evaluated for Parkinson’s disease. The nurse explains to the patient that Parkinson’s disease can be confirmed by
a. CT and MRI scans.
b. relief of symptoms with administration of dopaminergic agents.
c. the presence of tremors that increase during voluntary movement.
d. cerebral angiogram that reveals the presence of cerebral atherosclerosis.
b. relief of symptoms with administration of dopaminergic agents.
Although clinical manifestations are characteristic in PD, no laboratory or diagnostic tests are specific for the condition. A diagnosis is made when at least two of the three signs of the classic triad are present and it is confirmed with a positive response to antiparkinsonian medication. Research regarding the role of genetic testing and MRI to diagnose PD is ongoing. Essential tremors increase during voluntary movement whereas the tremors of PD are more prominent at rest.
Which observation of the patient made by the nurse is most indicative of Parkinson’s disease?
a. Large, embellished handwriting
b. Weakness of one leg resulting in a limping walk
c. Difficulty rising from a chair and beginning to walk
d. Onset of muscle spasms occurring with voluntary movement
c. Difficulty rising from a chair and beginning to walk
The bradykinesia of PD prevents automatic movements and activities such as beginning to walk, rising from a chair, or even swallowing saliva cannot be executed unless they are consciously willed. Handwriting is affected by the tremor and results in the writing trailing off at the end of words. Specific limb weakness and muscle spasms are not characteristic of PD.
A patient with Parkinson’s disease is started on levodopa. What should the nurse explain about this drug?
a. It stimulates dopamine receptors in the basal ganglia.
b. It promotes the release of dopamine from brain neurons.
c. It is a precursor of dopamine that is converted to dopamine in the brain.
d. It prevents the excessive breakdown of dopamine in the peripheral tissues.
c. It is a precursor of dopamine that is converted to dopamine in the brain.
Peripheral dopamine does not cross the blood-brain barrier but its precursor, levodopa, is able to enter the brain, where it is converted to dopamine, increasing the supply that is deficient in PD. Other drugs used to treat PD include bromocriptine, which stimulates dopamine receptors in the basal ganglia, and amantadine, which blocks the reuptake of dopamine into presynaptic neurons. Carbidopa is an agent that is usually administered with levodopa to prevent the levodopa from being metabolized in peripheral tissues before it can reach the brain.
To reduce the risk for falls in the patient with Parkinson’s disease, what should the nurse teach the patient to do?
a. Use an elevated toilet seat.
b. Use a walker or cane for support.
c. Consciously lift the toes when stepping.
d. Rock side to side to initiate leg movements.
c. Consciously lift the toes when stepping.
The shuffling gait of PD causes the patient to be off
balance and at risk for falling. Teaching the patient to
use a wide stance with the feet apart, to lift the toes when walking, and to look ahead helps to promote a more balanced gait. Use of an elevated toilet seat and rocking from side to side will enable a patient to initiate movement. Canes and walkers are difficult for patients with PD to maneuver and may make the patient more prone to injury.
A patient with myasthenia gravis is admitted to the hospital with respiratory insufficiency and severe weakness. When is a diagnosis of cholinergic crisis made?
a. The patient’s respiration is impaired because of muscle weakness.
b. Administration of edrophonium (Tensilon) increases muscle weakness.
c. Administration of edrophonium (Tensilon) results in improved muscle contractility.
d. EMG reveals decreased response to repeated stimulation of muscles.
b. Administration of edrophonium (Tensilon) increases muscle weakness
The reduction of the acetylcholine (ACh) effect in myasthenia gravis (MG) is treated with anticholinesterase drugs, which prolong the action of ACh at the neuromuscular synapse, but too much of these drugs will cause a cholinergic crisis with symptoms very similar to those of MG. To determine whether the patient's manifestations are due to a deficiency of ACh or to too much anticholinesterase drug, the anticholinesterase drug edrophonium chloride (Tensilon) is administered. If the patient is in cholinergic crisis, the patient's symptoms will worsen; if the patient is in a myasthenic crisis, the patient will improve.
During care of a patient in myasthenic crisis, maintenance of what is the nurse’s first priority for the patient?
a. Mobility
b. Nutrition
c. Respiratory function
d. Verbal communication
c. Respiratory function
The patient in myasthenic crisis has severe weakness and fatigability of all skeletal muscles, affecting the patient’s ability to breathe, swallow, talk, and move. However, the priority of nursing care is monitoring and maintaining adequate ventilation.
When providing care for a patient with ALS, the nurse recognizes what as one of the most distressing problems experienced by the patient?
a. Painful spasticity of the face and extremities
b. Retention of cognitive function with total degeneration of motor function
c. Uncontrollable writhing and twisting movements of the face, limbs, and body
d. Knowledge that there is a 50% chance the disease has been passed to any offspring
b. Retention of cognitive function with total degeneration of motor function
In ALS there is gradual degeneration of motor neurons with extreme muscle wasting from lack of stimulation and use. However, cognitive function is not impaired and patients feel trapped in a dying body. Chorea manifested by writhing, involuntary movements is characteristic of HD. As an autosomal dominant genetic disease, HD also has a 50% chance of being passed to each offspring.
