Lewis: Chapter 60: Spinal Cord and Peripheral Nerve Problems Flashcards
What information would the nurse seek from a patient with newly diagnosed trigeminal neuralgia?
a. Visual problems caused by ptosis.
b. Poor appetite caused by loss of taste.
c. Triggers leading to facial discomfort.
d. Weakness on the affected side of the face.
ANS: C
The major clinical manifestation of trigeminal neuralgia is severe facial pain triggered by cutaneous stimulation of the nerve. Ptosis, loss of taste, and facial weakness are not characteristics of trigeminal neuralgia.
Which patient assessment would help the nurse identify potential complications of trigeminal neuralgia?
a. Have the patient clench the jaws.
b. Inspect the oral mucosa and teeth.
c. Palpate the face to compare skin temperature bilaterally.
d. Identify trigger zones by lightly touching the affected side.
ANS: B
Oral hygiene is frequently neglected because of fear of triggering facial pain and may lead to gum disease, dental caries, or an abscess. Having the patient clench the facial muscles will not be useful because the sensory branches (rather than motor branches) of the nerve are affected by trigeminal neuralgia. Light touch and palpation may be triggers for pain and should be avoided.
What action would help the nurse evaluate outcomes of a glycerol rhizotomy for a patient with trigeminal neuralgia?
a. Inquire if the patient is doing daily facial exercises.
b. Question if the patient is using an eye shield at night.
c. Ask the patient about social activities with family and friends.
d. Observe the patient chewing with the unaffected side of the mouth.
ANS: C
Because withdrawal from social activities is a common manifestation of trigeminal neuralgia, asking about social activities will help in evaluating if the patient’s symptoms have improved. Glycerol rhizotomy does not damage the corneal reflex or motor functions of the trigeminal nerve, so there is no need to use an eye shield, do facial exercises, or take precautions with chewing.
Which action would the nurse include in the plan of care for a patient who is experiencing pain from trigeminal neuralgia?
a. Assess fluid and dietary intake.
b. Apply ice packs for 20 minutes.
c. Teach facial relaxation techniques.
d. Spend time talking with the patient.
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. Because stimulation by touch is the precipitating factor for pain, relaxation of the facial muscles will not improve symptoms. Application of ice is likely to precipitate pain. The patient will not want to engage in conversation, which may precipitate attacks.
The nurse identifies a patient with type 1 diabetes and a history of herpes simplex infection as being at risk for Bell’s palsy. Which information should the nurse include in teaching the patient?
a. “You may be able to prevent Bell’s palsy by doing facial exercises regularly.”
b. “Prophylactic treatment of herpes with antiviral agents prevents Bell’s palsy.”
c. “Medications to treat Bell’s palsy work only if started before paralysis onset.”
d. “Call the doctor if you experience pain or develop herpes lesions near the ear.”
ANS: D
Pain or herpes lesions near the ear may indicate the onset of Bell’s palsy, and rapid corticosteroid treatment may reduce the duration of Bell’s palsy symptoms. Antiviral therapy for herpes simplex does not reduce the risk for Bell’s palsy. Corticosteroid therapy will be most effective in reducing symptoms if started before paralysis is complete but will still be somewhat effective when started later. Facial exercises do not prevent Bell’s palsy.
A patient with Bell’s palsy refuses to eat while others are present because of embarrassment about drooling. What is the nurse’s best response?
a. Respect the patient’s feelings and arrange for privacy at mealtimes.
b. Teach the patient to chew food on the unaffected side of the mouth.
c. Offer the patient liquid nutritional supplements at frequent intervals.
d. Discuss the patient’s concerns with visitors who arrive at mealtimes.
ANS: A
The patient’s desire for privacy should be respected to encourage adequate nutrition and reduce patient embarrassment. Liquid supplements may help maintain nutrition but will reduce the patient’s enjoyment of the taste of food. It would be inappropriate for the nurse to discuss the patient’s embarrassment with visitors unless the patient wishes to share this information. Chewing on the unaffected side of the mouth will enhance nutrition and enjoyment of food but will not decrease the drooling.
To prevent autonomic dysreflexia, which nursing action should the home health nurse include in the plan of care for a patient who has paraplegia at the T4 level?
a. Support selection of a high-protein diet.
b. Discuss options for sexuality and fertility.
c. Assist to plan a prescribed bowel program.
d. Use quad coughing to strengthen cough efforts.
ANS: C
Fecal impaction is a common stimulus for autonomic hyperreflexia. Dietary protein, coughing, and discussing sexuality and fertility should be included in the plan of care but will not reduce the risk for autonomic hyperreflexia.
Which assessment data for a patient who has Guillain-Barré syndrome will require the nurse’s most immediate action?
a. The patient’s sacral area skin is reddened.
b. The patient reports severe pain in the feet.
c. The patient is continuously drooling saliva.
d. The patient’s blood pressure (BP) is 150/82 mm Hg.
ANS: C
Drooling indicates decreased ability to swallow, which places the patient at risk for aspiration and requires rapid nursing and collaborative actions such as suctioning and possible endotracheal intubation. The foot pain should be treated with appropriate analgesics, the BP requires ongoing monitoring, and the skin integrity requires intervention, but these actions are not as urgently needed as maintenance of respiratory function.
A patient hospitalized with a new diagnosis of Guillain-Barré syndrome has numbness and weakness of both feet. Which intervention should the nurse anticipate?
a. Infusion of immunoglobulin
b. Administration of corticosteroids
c. Intubation and mechanical ventilation
d. Insertion of a nasogastric (NG) feeding tube
ANS: A
Because Guillain-Barré syndrome is in the earliest stages (as evidenced by the symptoms), use of high-dose immunoglobulin is appropriate to reduce the extent and length of symptoms. Mechanical ventilation and enteral nutrition may be used later in the progression of the syndrome but are not needed now. Corticosteroids are not helpful in reducing the duration or symptoms of the syndrome.
A construction worker arrives at an urgent care center with a deep puncture wound from a rusty nail. The patient reports having had a tetanus booster 6 years ago. What intervention 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
ANS: B
If the patient has not been immunized in the past 5 years, administration of the Td booster is indicated because the wound is deep. Immune globulin administration is given by the IM route if the patient has no previous immunization. Administration of a series of immunization is not indicated. TIG is not indicated for this patient, and a test dose is not needed for immune globulin.
The nurse is admitting a patient who has a neck fracture at the C6 level to the intensive care unit. Which finding on the nursing assessment is congruent with neurogenic shock?
a. Involuntary and spastic movement
b. Hypotension and warm extremities
c. Hyperactive reflexes below the injury
d. Lack of sensation or movement below the injury
ANS: B
Neurogenic shock is characterized by hypotension, bradycardia, and vasodilation leading to warm skin temperature. Spasticity and hyperactive reflexes do not occur at this stage of spinal cord injury. Lack of movement and sensation indicate spinal cord injury but not neurogenic shock.
A patient has an incomplete left spinal cord lesion at the level of T7, resulting in Brown-Séquard syndrome. Which action should the nurse include in the plan of care?
a. Assessment of the patient for right arm weakness
b. Assessment of the patient for increased right leg pain
c. Positioning the patient’s left leg when turning the patient
d. Teaching the patient to verify the position of the right leg
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 left leg. Pain sensation will be lost in the patient’s right leg. Arm weakness will not be a problem for a patient with a T7 injury. The patient will retain position sense for the right leg.
What should the nurse explain to the patient who has a T2 spinal cord transection injury?
a. Total loss of respiratory function may occur.
b. Function of both arms should be maintained.
c. Use of the patient’s shoulders will be limited.
d. Tachycardia is common with this type of injury.
ANS: B
The patient with a T2 injury can expect to retain full motor and sensory function of the arms. Use of only the shoulders is associated with cervical spine injury. Loss of respiratory function occurs with cervical spine injuries. Bradycardia is associated with injuries above the T6 level.
A patient with paraplegia resulting from a T9 spinal cord injury has a neurogenic reflexic bladder. Which action should the nurse include in the plan of care?
a. Teach the patient to use the Credé method.
b. Instruct the patient how to self-catheterize.
c. Catheterize for residual urine after voiding.
d. Assist the patient to the toilet every 2 hours.
ANS: B
Because the patient’s bladder is spastic and will empty in response to overstretching of the bladder wall, the most appropriate method is to avoid incontinence by emptying the bladder at regular intervals through intermittent catheterization. Assisting the patient to the toilet will not be helpful because the bladder will not empty. The Credé method is more appropriate for a bladder that is flaccid, such as occurs with areflexic neurogenic bladder. Catheterization after voiding will not resolve the patient’s incontinence.
What should the nurse include in a rehabilitation plan as an appropriate goal for a 30-yr-old patient with a C6 spinal cord injury?
a. Drive a car with powered hand controls.
b. Propel a manual wheelchair on a flat surface.
c. Turn and reposition independently when in bed.
d. Transfer independently to and from a wheelchair.
ANS: B
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.