Med Surg - Exam 3 - Ch 61 (Peripheral Nerve and Spinal Cord)

Question 1

A patient is diagnosed with Bell’s palsy. What information should the nurse teach the patient about Bell’s palsy (select all that apply)?

a. Bell’s palsy affects the motor branches of the facial nerve.
b. Antiseizure drugs are the drugs of choice for treatment of Bell’s palsy.
c. Nutrition and avoidance of hot foods or beverages are special needs of this patient.
d. Herpes simplex virus 1 is strongly associated as a precipitating factor in the development of Bell’s palsy.
e. Moist heat, gentle massage, electrical stimulation of the nerve, and exercises are prescribed to treat Bell’s palsy.
f. An inability to close the eyelid, with an upward movement of the eyeball when closure is attempted, is evident.

Answer 1

a. Bell’s palsy affects the motor branches of the facial nerve.
d. Herpes simplex virus 1 is strongly associated as a precipitating factor in the development of Bell’s palsy.
e. Moist heat, gentle massage, electrical stimulation of the nerve, and exercises are prescribed to treat Bell’s palsy.
f. An inability to close the eyelid, with an upward movement of the eyeball when closure is attempted, is evident.

Bell’s palsy affects the motor branches of the facial nerve. It is treated with corticosteroids, usually prednisone. Herpes simplex virus 1 may be a precipitating factor. Moist heat, gentle massage, electrical nerve stimulation, and exercises are prescribed. Care must be taken to protect the eye with sunglasses, artificial tears or gel, and possibly taping the eyelid closed at night. Oral hygiene is important but avoidance of hot foods is not needed.

Question 2

When planning care for the patient with trigeminal neuralgia, which patient outcome should the nurse set as the highest priority?

a. Relief of pain
b. Protection of the cornea
c. Maintenance of nutrition
d. Maintenance of positive body image

Answer 2

a. Relief of pain

The pain of trigeminal neuralgia is excruciating and it may occur in clusters that continue for hours. The condition is considered benign with no major effects except the pain. Corneal exposure is a problem in Bell’s palsy or it may occur following surgery for the treatment of trigeminal neuralgia. Maintenance of nutrition is important but not urgent because chewing may trigger trigeminal neuralgia and patients then avoid eating. Except during an attack, there is no change in facial appearance in a patient with trigeminal neuralgia and body image is more disturbed in response to the paralysis typical of Bell’s palsy.

Question 3

Surgical intervention is being considered for a patient with trigeminal neuralgia. The nurse recognizes that which procedure has the least residual effects with a positive outcome?

a. Glycerol rhizotomy
b. Gamma knife radiosurgery
c. Microvascular decompression
d. Percutaneous radiofrequency rhizotomy

Answer 3

a. Glycerol rhizotomy

Although percutaneous radiofrequency and microvascular decompression provide the greatest relief of pain, glycerol rhizotomy causes less sensory loss and fewer sensory aberrations with comparable pain relief and less danger. Gamma knife radiosurgery provides precise high doses of radiation useful for persistent pain after other surgery.

Question 4

What should the nurse do when providing care for a patient with an acute attack of trigeminal neuralgia?

a. Carry out all hygiene and oral care for the patient.
b. Use conversation to distract the patient from pain.
c. Maintain a quiet, comfortable, draft-free environment.
d. Have the patient examine the mouth after each meal for residual food.

Answer 4

c. Maintain a quiet, comfortable, draft-free environment.

Because attacks of trigeminal neuralgia may be precipitated by hot or cold air movement on the face, jarring movements, or talking, the environment should be of moderate temperature and free of drafts and patients should not be expected to converse during the acute period. Patients offer prefer to carry out their own care because they are afraid someone may inadvertently injure them or precipitate an attack. The nurse should stress that oral hygiene be performed because patients often avoid it but residual food in the mouth after eating occurs more frequently with Bell’s palsy.

Question 5

A patient is admitted to the hospital with Guillain-Barre syndrome. She had weakness in her feet and ankles that has progressed to weakness with numbness and tingling in both legs. During the acute phase of the illness, what should the nurse know about Guillain-Barre syndrome?

a. The most important aspect of care is to monitor the patient’s respiratory rate and depth and vital capacity.
b. Early treatment with corticosteroids can suppress the immune response and prevent ascending nerve damage.
c. The most serious complication of this condition is ascending demyelination of the peripheral nerves and the cranial nerves.
d. Although voluntary motor neurons are damaged by the inflammatory response, the autonomic nervous system is unaffected by the disease.

Answer 5

a. The most important aspect of care is to monitor the patient’s respiratory rate and depth and vital capacity.

The most serious complication of Guillain-Barre syndrome is respiratory failure and it is essential that respiratory rate and depth and vital capacity are monitored to detect involvement of the autonomic nerves that affect respiration. Corticosteroids may be used in treatment but do not appear to have an effect on the prognosis or duration of the disease. Rather, plasmapheresis or administration of high-dose immunoglobin does result in shortening recovery time. The peripheral nerves of both the sympathetic and the parasympathetic nervous systems are involved in the disease and may lead to orthostatic hypotension, hypertension, and abnormal vagal responses affecting the heart. Guillain-Barre syndrome may affect the lower brainstem and cranial nerves (CNs) VII, VI, III, XII, V, and X, affecting facial, eye, and swallowing functions.

Question 6

A patient with Guillain-Barre syndrome asks whether he is going to die as the paralysis spreads toward his chest. In responding to the patient, what should the nurse know to be able to answer this question?

a. Patients who require ventilatory support almost always die.
b. Death occurs when nerve damage affects the brain and meninges.
c. Most patients with Guillain-Barre syndrome make a complete recovery.
d. If death can be prevented, residual paralysis and sensory impairment are usually permanent.

Answer 6

c. Most patients with Guillain-Barre syndrome make a complete recovery.

As the nerve involvement ascends, it is very frightening for the patient but 85% to 95% of patients with Guillain-Barre syndrome recover completely with care, although 30% may have a residual weakness. Patients also recover if ventilatory support is provided during respiratory failure. Guillain-Barre syndrome only affects peripheral nerves and does not affect the brain.

Question 7

The nurse is providing care for a patient who has been diagnosed with Guillain-Barré syndrome. Which assessment should be the nurse’s priority?

a. Pain assessment
b. Glasgow Coma Scale
c. Respiratory assessment
d. Musculoskeletal assessment

Answer 7

c. Respiratory assessment

Although all of the assessments are necessary in the care of patients with Guillain-Barré syndrome, the acute risk of respiratory failure necessitates vigilant monitoring of the patient’s respiratory status.

Question 8

The patient with peripheral facial paresis on the left side of her face is diagnosed with Bell’s palsy. What should the nurse include in teaching the patient about self-care (select all that apply)?

a. Administration of antiseizure medications
b. Preparing for a nerve block to relieve pain
c. Administration of corticosteroid medications
d. Dark glasses and artificial tears to protect the eyes
e. Surgeries available if conservative therapy is not effective

Answer 8

c. Administration of corticosteroid medications
d. Dark glasses and artificial tears to protect the eyes

Self-care for Bell’s palsy includes corticosteroid medications to decrease inflammation of the facial nerve (CNVII) and protecting the cornea from drying out because of the inability to close the eyelid. Antiseizure medications, a nerve block, or surgeries are used for trigeminal neuralgia.

Question 9

During assessment of the patient with trigeminal neuralgia, the nurse should (select all that apply)

a. inspect all aspects of the mouth and teeth.
b. assess the gag reflex and respiratory rate and depth.
c. lightly palpate the affected side of the face for edema.
d. test for temperature and sensation perception on the face.
e. ask for the patient to describe factors that initiate an episode.

Answer 9

a. inspect all aspects of the mouth and teeth.
d. test for temperature and sensation perception on the face.
e. ask for the patient to describe factors that initiate an episode.

Assessment of the attacks, including the triggering factors, characteristics, frequency, and pain management techniques, helps the nurse plan for patient care. Painful episodes are usually triggered by light cutaneous stimulation at a specific point (i.e., trigger zone) along the distribution of the nerve branches. Precipitating stimuli include chewing, tooth brushing, a hot or cold blast of air on the face, washing the face, yawning, or talking. Touch and tickle seem to predominate as causative triggers, rather than pain or changes in ambient temperature. The nursing assessment should include the patient’s nutritional status, hygiene (especially oral), and behavior (including withdrawal). As a result of the attacks, the patient may eat improperly, neglect hygienic practices, wear a cloth over the face, and withdraw from interaction with others.

Question 10

During routine assessment of a patient with Guillain-Barre syndrome, the nurse finds the patient is short of breath. The patient’s respiratory distress is caused by

a. elevated protein levels in the CSF.
b. immobility resulting from ascending paralysis.
c. degeneration of motor neurons in the brainstem and spinal cord.
d. paralysis ascending to the nerves that stimulate the thoracic area.

Answer 10

d. paralysis ascending to the nerves that stimulate the thoracic area.

Guillain-Barré syndrome is characterized by ascending, symmetric paralysis that usually affects cranial nerves and the peripheral nervous system. The most serious complication of this syndrome is respiratory failure, which occurs as the paralysis progresses to the nerves that innervate the thoracic area.

Question 11

The client is admitted with a diagnosis of trigeminal neuralgia. Which assessment data would the nurse expect to find in this client?

a. Joint pain of the neck and jaw.
b. Unconscious grinding of the teeth during sleep.
c. Sudden severe unilateral facial pain.
d. Progressive loss of calcium in the nasal septum.

Answer 11

c. Sudden severe unilateral facial pain.

Trigeminal neuralgia affects the 5th cranial nerve and is characterized by paroxysms of pain in the area innervated by the three branches of the nerve. The unilateral nature of the pain is an important diagnostic characteristic. The disorder is also known as tic douloureux.

a - Joint pain is usually associated with some type of arthritis.
b - Unconscious grinding of the teeth during sleep is usually associated with temporomandibular joint (TMJ) disorder.
d - The nasal structure is not made up of bone.

Question 12

The client recently has been diagnosed with trigeminal neuralgia. Which intervention is the most important for the nurse to implement with the client?

a. Assess the client’s sense of smell and taste.
b. Teach the client how to care for the eyes.
c. Instruct the client to have carbamazepine (Tegretol) levels monitored regularly.
d. Assist the client to identify factors that trigger an attack.

Answer 12

d. Assist the client to identify factors that trigger an attack.

Stimulating specific areas of the face, called trigger zones, may initiate the onset of pain. Therefore, the nurse should help the client identify situations that exacerbate the condition, such as chewing gum, eating, brushing the teeth, or being exposed to a draft of cold air.

a - The client’s sense of smell and taste are not affected.
b - The cornea is at risk for abrasions because of the twitching, which causes irritation.
c - Tegretol is the treatment of choice for trigeminal neuralgia, but it is not the most important intervention when the client is first diagnosed with this condition.

Question 13

The client comes to the clinic and reports a sudden drooping of the left side of the face and complains of pain in that area. The nurse notes that the client cannot wrinkle the forehead or close the left eye. Which condition should the nurse suspect?

a. Bell’s palsy.
b. Right-sided stroke.
c. Tetany.
d. Mononeuropathy.

Answer 13

a. Bell’s palsy.

Bell’s palsy, called facial paralysis, is a disorder of the 7th cranial nerve (facial nerve) characterized by unilateral paralysis of facial muscles.

b - These are symptoms of a left-sided stroke.
c - Tetany is due to low calcium levels. In this disorder, the face twitches when touched; this is known as a positive Chvostek’s sign.
d - Mononeuropathy is limited to a single peripheral nerve and its branches and occurs because the trunk of the nerve is compressed, such as in carpal tunnel syndrome.

Question 14

In planning community education for prevention of spinal cord injuries, what group should the nurse target?

a. Older men
b. Teenage girls
c. Elementary school-age children
d. Adolescent and young adult men

Answer 14

d. Adolescent and young adult men

Spinal cord injuries are highest in adolescent and young adult men between the ages of 16 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.

Question 15

A 70-year-old patient is admitted after falling from his roof. He has a spinal cord injury at the C7 level. What findings during the assessment identify the presence of spinal shock?

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

Answer 15

b. Tetraplegia with total sensory loss

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.

Question 16

Which syndrome of incomplete spinal cord lesion is described as cord damage common in the cervical region resulting in greater weakness in upper extremities than lower?

a. Central cord syndrome
b. Anterior cord syndrome
c. Posterior cord syndrome
d. Cauda equina and conus medullaris syndromes

Answer 16

a. Central cord syndrome

In central cord syndrome, motor weakness and sensory loss are present in both upper and lower extremities, with upper extremities affected more than lower extremities.

Question 17

What causes an initial incomplete spinal cord injury to result in complete cord damage?

a. Edematous compression of the cord above the level of 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. Mechanical transection of the cord by sharp vertebral bone fragments after the initial injury.

Answer 17

c. Infarction and necrosis of the cord caused by edema, hemorrhage, and metabolites.

The primary injury of the spinal cord rarely affects the entire cord but the pathophysiology of secondary injury may result in damage that is the same as mechanical severence of the cord. Complete cord dissolution occurs through the 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 the inflammatory response may compress the spinal cord as well as increase the damage as it extends above and below the injury site.

Question 18

A patient with a spinal cord injury has spinal shock. The nurse plans care for the patient based on what knowledge?

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 function below the level of injury but autonomic functions are not affected.

Answer 18

c. Resolution of spinal shock is manifested by spasticity, hyperreflexia, and reflex emptying of the bladder.

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, although hyperreflexive and spastic, signals the end of spinal shock. Rehabilitation activities are not contraindicated during spinal shock and should be instituted if the patient’s cardiopulmonary status is stable. Neurogenic shock results from loss of vascular tone caused by the injury and is manifested by hypotension, peripheral vasodilation, and decreased cardiac output (CO). Sympathetic function is impaired below 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 organs below the injury, which includes autonomic functions.

Question 19

Two days following a spinal cord injury, a patient asks continually about the extent of impairment that will result from the injury. What is the best response by the nurse?

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, MRI will be done to reveal the extent of your cord damage.”
d. “Because long-term rehabilitation can affect the return of function, it will be years before we can tell what the complete effect will be.”

Answer 19

b. “The extent of your injury cannot be determined until the secondary injury to the cord is resolved.”

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 may be inappropriate and excessive, causing spasms that complicate rehabilitation.

Question 20

The patient was in a traffic collision and is experiencing the loss of function below C4. Which effect must the nurse be aware of to provide priority care for the patient?

a. Respiratory diaphragmatic breathing
b. Loss of all respiratory muscle function
c. Decreased response of the sympathetic nervous system
d. GI hypomotility with paralytic ileus and gastric distention

Answer 20

a. Respiratory diaphragmatic breathing

Spinal injury below C4 will result in diaphragmatic breathing and usually hypoventilation from decreased vital capacity and tidal volume from intercostal muscle impairment. The nurse’s priority actions will be to monitor rate, rhythm, depth, and effort of breathing to observe for changes from the baseline and identify the need for ventilation assistance. Loss of all respiratory muscle function occurs above C4 and the patient requires mechanical ventilation to survive. Although the decreased sympathetic nervous system response (from injuries above T6) and GI hypomotility (paralytic ileus and gastric distention) will occur (with injuries above T5), they are not the patient’s initial priority needs.

Question 21

A patient is admitted to the emergency department with a spinal cord injury at the level of T2. Which finding will be of most concern to the nurse?

a. SpO2 of 92%
b. Heart rate of 42 bpm
c. Blood pressure of 88/60 mm Hg
d. Loss of motor and sensory function in arms and legs

Answer 21

b. Heart rate of 42 bpm

Neurogenic shock associated with cord injuries above the level of T6 greatly decreases the effect of the sympathetic nervous system and bradycardia and hypotension occur. A heart rate of 42 bpm is not adequate to meet the oxygen needs of the body. While low, the blood pressure is not at a critical point. The oxygen saturation is satisfactory and the motor and sensory losses are expected.

Question 22

The patient’s spinal cord injury is at T4. What is the highest-level goal of rehabilitation that is realistic for this patient to have?

a. Indoor mobility in manual wheelchair
b. Ambulate with crutches and leg braces
c. Be independent in self-care and wheelchair use
d. Completely independent ambulation with short leg braces and canes

Answer 22

c. Be independent in self-care and wheelchair use

With the injury at T4, the highest level realistic goal for this patient is to be able to be independent in self-care and wheelchair use because arm function will not be affected. Indoor mobility in a manual wheelchair will be achievable but it is not the highest-level goal. Ambulating with crutches and leg braces can be achieved only by patients with injuries in T6-12 area. Independent ambulation with short leg braces and canes could occur for a patient with an L3-4 injury. (See Table 61-4.)

Question 23

What is one indication for early surgical therapy of the patient with a spinal cord injury?

a. There is incomplete cord lesion involvement.
b. The ligaments that support the spine are torn.
c. A high cervical injury causes the loss of respiratory function.
d. Evidence of continued compression of the cord is apparent.

Answer 23

d. Evidence of continued compression of the cord is apparent.

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.

Question 24

A patient is admitted to the emergency department with a possible cervical spinal cord injury following an automobile crash. During admission of the patient, what is the highest priority for the nurse?

a. Maintaining a patent airway
b. Maintaining immobilization of the cervical spine
c. Assessing the patient for head and other injuries
d. Assessing the patient’s motor and sensory function

Answer 24

a. Maintaining a patent airway

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 the 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 patient’s neurologic status.

Question 25

Without surgical stabilization, what method of immobilization for the patient with a cervical spinal cord injury should the nurse expect to be used?

a. Kinetic beds
b. Hard cervical collar
c. Skeletal traction with skull tongs
d. Sternal-occipital-mandibular immobilizer brace

Answer 25

c. Skeletal traction with skull tongs

The development of better surgical stabilization has made surgery the more frequent treatment of cervical injuries. However, when surgery cannot be done, skeletal traction with the use of Crutchfield, Vinke, or other types of skull tongs is required to immobilize the cervical vertebrae, even if a fracture has not occurred. Hard cervical collars or sternal-occipital-mandibular immobilizer brace may be used after cervical stabilization surgery or for minor injuries or stabilization during emergency transport of the patient. Sandbags may also be 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.

Question 26

The health care provider has ordered IV dopamine (Intropin) for a patient in the emergency department with a spinal cord injury. The nurse determines that the drug is having the desired effect when what is observed in patient assessment?

a. Heart rate of 68 bpm
b. Respiratory rate of 24
c. Blood pressure of 106/82 mm Hg
d. Temperature of 96.8F (36.0C)

Answer 26

c. Blood pressure of 106/82 mm Hg

Dopamine is a vasopressor that is used to maintain blood pressure during states of hypotension that occur during neurogenic shock associated with spinal cord injury. Atropine would be used to treat bradycardia. The temperature reflects some degree of poikilothermism but this is not treated with medications.

Question 27

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, what should be the nurse’s first action?

a. Institute 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.

Answer 27

c. Assess lung sounds and respiratory rate and depth.

Because pneumonia and atelectasis are potential problems related to ineffective coughing and the loss of intercostal and abdominal muscle function, the nurse should assess the patient’s breath sounds and respiratory function to determine whether secretions are being retained or whether there is progression of respiratory impairment. Suctioning is not indicated unless lung sounds indicate retained secretions. Position changes will help to mobilize secretions. Intubation and mechanical ventilation are used if the patient becomes exhausted from labored breathing or if arterial blood gases (ABGs) deteriorate.

Question 28

Following a T2 spinal cord injury, the patient develops paralytic ileus. While this condition is present, what should the nurse anticipate that the patient will need?

a. IV fluids
b. Tube feedings
c. Parenteral nutrition
d. Nasogastric suctioning

Answer 28

d. Nasogastric suctioning

During the first 2 to 3 days after a spinal cord injury, paralytic ileus may occur and nasogastric 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 have difficulty swallowing and not until peristalsis returns. Parenteral nutrition would be used only if the paralytic ileus was unusually prolonged.

Question 29

How is urinary function maintained during the acute phase of spinal cord injury?

a. An indwelling catheter
b. Intermittent catherization
c. Insertion of a suprapubic catheter
d. Use of incontinent pads to protect the skin

Answer 29

a. An indwelling catheter

During the acute phase of spinal cord injury, the bladder is hypotonic, causing urinary retention with the risk for reflux into the kidney or rupture of the bladder. An indwelling catheter is used to keep the bladder empty and to monitor urinary output. Intermittent catheterization or other urinary drainage methods may be used in long-term bladder management. Use of incontinent pads is inappropriate because they do not help the bladder to empty.

Question 30

A week following a spinal cord injury at T2, a patient experiences movement in his leg and tells the nurse that he is recovering some function. What is the nurse’s best response to the patient?

a. “It really is too soon to know if you will have a return of function.”
b. “That could really be a positive finding. Can you show me the movement?”
c. “That’s wonderful. We will start exercising your legs more frequently now.”
d. “I’m sorry but the movement is only a reflex and does not indicate normal function.”

Answer 30

b. “That could really be a positive finding. Can you show me the movement?”

When spinal shock ends, reflex movement and spasms will occur, which may be mistaken for return of function; however, 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.

Question 31

A patient with a spinal cord injury suddenly experiences a throbbing headache, flushed skin, and diaphoresis above the level of injury. After checking the patient’s vital signs and finding a systolic blood pressure of 210 and a heart rate of 48 bpm, number the following nursing actions in priority from highest to lowest.
___ a. Administer ordered prn nifedipine (Procardia).
___ b. Check for bladder distention.
___ c. Document the occurrence, treatment, and response.
___ d. Place call to physician.
___ e. Raise the head of bed (HOB) to 45 degrees and above.
___ f. Loosen tight clothing on the patient.

Answer 31

1 - e. Raise the head of bed (HOB) to 45 degrees and above.
2 - b. Check for bladder distention.
3 - d. Place call to physician.
4 - f. Loosen tight clothing on the patient.
5 - a. Administer ordered prn nifedipine (Procardia).
6 - c. Document the occurrence, treatment, and response.

The patient is experiencing autonomic dysreflexia. The initial response by the nurse should be to elevate the head of bed (HOB) to decrease blood pressure (BP) and then to remove noxious stimulation. Frequently the trigger is bladder distention, which can be dealt with quickly. The physician needs to be notified as soon as possible and, depending on the communication system available to the nurse, he or she should have the call placed. Meanwhile, the nurse should stay with the patient and loosen any restrictive clothing. The physician may order an antihypertensive and documentation should be an accurate and thorough description of the entire episode.

Question 32

A patient with paraplegia has developed an irritable bladder with reflex emptying. What will be most helpful for the nurse to teach 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

Answer 32

b. How to perform intermittent self-catheterization

Intermittent self-catheterization five to six times a day is the recommended method of bladder management for the patient with a spinal cord injury and reflexic neurogenic bladder because it more closely mimics normal emptying and has less potential for infection. The patient and family should be taught the procedure using clean technique and if the patient has use of the arms, self-catheterization should be performed. Indwelling catheterization is used during the acute phase to prevent overdistention of the bladder and surgical urinary diversions are used if urinary complications occur.

Question 33

In counseling patients with spinal cord lesions regarding sexual function, how should the nurse advise a male patient with a complete lower motor neuron lesion?

a. He is most likely to have reflexogenic erections and may experience orgasm if ejaculation occurs.
b. He may have uncontrolled reflex erections but orgasm and ejaculation are usually not possible.
c. He has a lesion with the greatest possibility of successful psychogenic erection with ejaculation and orgasm.
d. He will probably be unable to have either psychogenic or reflexogenic erections and no ejaculation or orgasm.

Answer 33

d. He will probably be unable to have either psychogenic or reflexogenic erections and no ejaculation or orgasm.

Most patients with a complete lower motor neuron lesion unable to have either psychogenic or reflexogenic erections and alternative 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 likely to experience reflexogenic erections with ejaculation. Patients with complete upper motor neuron lesions usually have only reflex sexual function with rare ejaculation.

Question 34

During the patient’s process of grieving for the losses resulting from spinal cord injury, what should the nurse do?

a. Help the patient to understand that working through the grief will be a lifelong process.
b. Assist the patient to move through all stages of the mourning process to acceptance.
c. Let the patient know that anger directed at the staff or the family s not a positive coping mechanism.
d. Facilitate the grieving process so that it is completed by the time the patient is discharged from rehabilitation.

Answer 34

a. Help the patient to understand that working through the grief will be a lifelong process.

Working through the grief process is a lifelong process that is triggered by new experiences, such as marriage, child rearing, employment, or illness, which the patient must adjust to throughout life within the context of his or her disability. The goal of recovery is related to adjustment rather than acceptance and many patients do not experience all components of the grief process. During the anger phase, patients should be allowed outbursts and the nurse may use humor to displace some of the patient’s anger.

Question 35

A patient with a metastatic tumor of the spinal cord is scheduled for the removal of the tumor by a laminectomy. In planning postoperative care for the patient, what should the nurse recognize?

a. Most cord tumors cause autodestruction of the cord as in traumatic injuries.
b. Metastatic tumors are commonly extradural lesions that are treated palliatively.
c. Radiation therapy is routinely administered following surgery for all malignant spinal cord tumors.
d. Because complete removal of intramedullary tumors is not possible, the surgery is considered palliative.

Answer 35

b. Metastatic tumors are commonly extradural lesions that are treated palliatively.

Most metastatic or secondary tumors are extradural lesions in which treatment, including surgery, is palliative. Primary spinal tumors may be removed with the goal of cure. Most tumors of the spinal cord are slow-growing, do not cause autodestruction, and, if removal is possible, can have complete function restored. Radiation is used to treat metastatic tumors that are sensitive to radiation and that have caused only minor neurologic deficits in the patient. Radiation s also used as adjuvant therapy to surgery for intramedullary tumors.

Question 36

When planning care for a patient who is experiencing acute attack of trigeminal neuralgia, the nurse sets the highest priority on the patient outcome of

a. Relief of pain
b. Relief of anxiety
c. Maintenance of oral hygiene
d. Maintenance of positive body image

Answer 36

a. Relief of pain

Question 37

Which nursing diagnosis will take priority for client as the Guillain-Barré syndrome progresses?

a. High risk for injury related to inability to ambulate and transfer safely.
b. Fear and anxiety related to hospitalization and loss of control.
c. Altered nutrition, less than body requirements, related to inability to swallow.
d. Ineffective breathing pattern related to progressive muscle weakness.

Answer 37

d. Ineffective breathing pattern related to progressive muscle weakness.

Question 38

A patient has an incomplete left spinal cord lesion at the level of T7, resulting in Brown-Séquard syndrome. Which nursing action should be included in the plan of care?

a. Assessment of the patient for 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 look at the right leg to verify its position

Answer 38

c. Positioning the patient’s left leg when turning the patient

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 on 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.

Question 39

Indicate the level of acute spinal cord injury at which the following effects occur.

1. Loss of all respiratory muscle function
2. Diaphragmatic breathing
3. Decreased response of the sympathetic nervous system
4. Paralytic ileus
5. Incontinence
6. Tetraplegia (Quadriplegia)
7. Paraplegia

Answer 39

Loss of all respiratory muscle function – Above C4
Diaphragmatic breathing – Below C4
Decreased response of the sympathetic nervous system – Above T6
Paralytic ileus – Above T5
Incontinence – Below T12
Tetraplegia (Quadriplegia) – C8 and above
Paraplegia – T1 and below

Question 40

Rank the following actions that the nurse performs when caring for a patient with possible C5 spinal cord trauma who is admitted to the emergency department

a. Infuse normal saline at 150 mL/hr.
b. Monitor cardiac rhythm and blood pressure.
c. Administer O2 using a non-rebreather mask.
d. Immobilize the patient’s head, neck, and spine.
e. Transfer the patient to radiology for spinal computed tomography (CT).

Answer 40

d. Immobilize the patient’s head, neck, and spine.
c. Administer O2 using a non-rebreather mask.
b. Monitor cardiac rhythm and blood pressure.
a. Infuse normal saline at 150 mL/hr.
e. Transfer the patient to radiology for spinal computed tomography (CT).

Question 41

Which of the following should the nurse use as the best method to assess for the development of deep vein thrombosis in a client with a spinal cord injury?

a. Homan’s sign.
b. Pain
c. Tenderness
d. Leg girth

Answer 41

d. Leg girth

Question 42

When taking care of a client with a spinal cord injury, the nurse would avoid which of the following measures to minimize the risk of autonomic dysreflexia

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

Answer 42

d. Limiting bladder catheterization to once every 12 hours

Question 43

Neurogenic shock is characterized by decreased reflexes, loss of sensation, and flaccid paralysis below the level of the injury.

a. True
b. False

Answer 43

b. False

Question 44

Which of the following symptoms is one of the characteristics of autonomic dysreflexia?

a. Tachycardia
b. Hypotension
c. Throbbing headache

Answer 44

c. Throbbing headache

Question 45

The nurse arrives at the site of a one-car motor-vehicle accident and stops to render aid. The driver of the car is unconscious. After stabilizing the client’s cervical spine, which action should the nurse take next?

a. Carefully remove the driver from the car.
b. Assess the client’s pupils for reaction.
c. Assess the client’s airway.
d. Attempt to wake the client up by shaking him.

Answer 45

c. Assess the client’s airway.
The nurse must maintain a patent airway. Airway is the first step in resuscitation.

a. The nurse should stabilize the neck prior to removal from the car.
b. The nurse must stabilize the client’s neck before doing any further assessment. Most nurses don’t carry penlights, and the client’s pupil reaction can be determined after stabilization.
d. Shaking the patient could cause further damage, possibly leading to paralysis.

Question 46

In assessing the client with a T12 SCI, which clinical manifestations would the nurse expect to find support the diagnosis of spinal shock?

a. No reflex activity below the waist.
b. Inability move upper extremities.
c. Complaints of a pounding headache.
d. Hypotension and bradycardia.

Answer 46

a. No reflex activity below the waist.
Spinal shock associated with SCI represents a sudden depression of reflex activity below the level of the injury. T12 is just above the waist; therefore, no reflex activity below the waist would be expected.

b. Assessment of the movement of the upper extremities would be more appropriate with a higher level injury; an injury in the cervical area might cause an inability to move the upper extremities.
c. Complaints of a pounding headache are not typical of a T12 spinal injury.
d. Hypotension (low blood pressure) and tachycardia (rapid heart rate) are signs of hypovolemic or septic shock, but these do not occur in spinal shock.

Question 47

The rehabilitation nurse caring for the client with an L1 SCI is developing the nursing care plan. Which intervention should the nurse implement?

a. Keep oxygen via nasal cannula on at all times.
b. Administer low-dose subcutaneous anticoagulants.
c. Perform active lower extremity ROM exercises.
d. Refer to a speech therapist for ventilator-assisted speech.

Answer 47

b. Administer low-dose subcutaneous anticoagulants.
Deep vein thrombosis (DVT) is a potential complication of immobility, which can occur because the client cannot move the lower extremities as a result of the L1 SCI. Low-dose anticoagulation therapy (Lovenox) helps prevent blood from coagulating, thereby preventing DVT’s.

a. Oxygen is administered initially to maintain a high arterial partial pressure of oxygen (PaO2) because hypoxemia can worsen a neurological deficit to the spinal cord initially, but this client is in the rehabilitation department and thus not in the initial stages of the injury.
c. The client is unable to move the lower extremities. The nurse should do passive ROM exercises.
d. A client with a spinal injury of C4 or above would be dependent on a ventilator for breathing, but a client with an L1 SCI would not.

Question 48

The nurse in the neurointensive care unit is caring for a client with a new C6 SCI who is breathing independently. Which nursing intervention should be implemented? Select all that apply.

1. Monitor the pulse oximetry reading.
2. Provide pureed foods six (6) times a day.
3. Encourage coughing and deep breathing.
4. Assess for autonomic dysreflexia.
5. Administer intravenous corticosteroids.

Answer 48

1. Monitor the pulse oximetry reading.
2. Encourage coughing and deep breathing.
3. Administer intravenous corticosteroids.
4. Oxygen is administered initially to prevent hypoxemia, which can worsen the spinal cord injury; therefore, the nurse should determine how much oxygen is reaching the periphery.
5. Breathing exercises are supervised by the nurse to increase the strength and endurance of inspiratory muscles, especially those of the diaphragm.
6. Corticosteroids are administered to decrease inflammation, which will decrease edema, and help prevent edema from ascending up the spinal cord, causing breathing difficulties.

Question 49

The client is diagnosed with an SCI and is scheduled for a MRI scan. Which question would be most appropriate for the nurse to ask prior to taking the client to the diagnostic test?

1. “Do you have trouble hearing?”
2. “Are you allergic to any type of dairy products?”
3. “Have you eaten anything in the last eight (8) hours?”
4. “Are you uncomfortable in closed spaces?”

Answer 49

4. “Are you uncomfortable in closed spaces?”

Duhhhhhh. I mean,

MRI scans are often done in a very confined space; many people who have claustrophobia must be medicated or even rescheduled for the procedure in an open MRI machine, which may be available if needed.

Question 50

The client with a C6 SCI is admitted to the emergency department complaining of a severe pounding headache and has a BP of 180/110. Which intervention should the emergency department nurse implement?

a. Keep the client flat in bed.
b. Dim the lights in the room.
c. Assess the bladder for distention.
d. Administer a narcotic analgesic.

Answer 50

c. Assess the bladder for distention.

This is an acute emergency caused by exaggerated autonomic responses to stimuli and only occurs after spinal shock has resolved in the client with a spinal cord injury above T6. The most common cause is a full bladder.

Question 51

The client with a cervical fracture is being discharged in a halo device. Which teaching instruction should the nurse discuss with the client?

a. Discuss how to correctly remove the insertion pins.
b. Instruct the client to report reddened or irritated skin areas.
c. Inform the client that the vest liner cannot be changed.
d. Encourage the client to remain in the recliner as much as possible.

Answer 51

b. Instruct the client to report reddened or irritated skin areas.

Reddened areas, especially under the brace, must be reported to the HCP because pressure ulcers can occur when wearing this appliance for an extended period.

Question 52

The ICU nurse is caring for a client with a T1 SCI. When the nurse elevates the head of the bed 30 degrees, the client complains of lightheadedness and dizziness. The client’s vital signs are T99.2, P98, R24, and BP 84/40. Which action should the nurse implement?

a. Notify the health care provider ASAP.
b. Calm the client down by talking therapeutically.
c. Increase the IV rate by 50 mL/hour.
d. Lower the head of the bed immediately.

Answer 52

d. Lower the head of the bed immediately.

For the first two weeks after an SCI above T7, the blood pressure tends to be unstable and low; slight elevations of the head of the bed can cause profound hypotension; therefore, the nurse should lower the head of the bed immediately.

Question 53

The nurse on the rehabilitation unit is caring for the following clients. Which client should the nurse assess first after receiving the change-of-shift report?

a. The client with a C6 SCI who is complaining of dyspnea and has crackles in the lungs.
b. The client with an L4 SCI who is crying and very upset about being discharged home.
c. The client with an L2 SCI who is complaining of a headache and feeling very hot.
d. The client with a T4 SCI who is unable to move the lower extremities.

Answer 53

a. The client with a C6 SCI who is complaining of dyspnea and has crackles in the lungs.

This client has signs/symptoms of a respiratory complication and should be assessed first.

Question 54

Which should be the nurse’s first intervention with the client diagnosed with Bell’s palsy?

a. Explain that this disorder will resolve within a month.
b. Tell the client to apply heat to the involved side of the face.
c. Encourage them to eat a soft diet.
d. Teach the client to protect the affected eye from injury.

Answer 54

d. Teach the client to protect the affected eye from injury.

Teaching the client to protect the eye is priority because the eye does not close completely and the blink reflex is diminished, making the eye vulnerable to injury. The client should wear an eye patch at night and wraparound sunglasses or goggles during the day; he or she may also need artificial tears.

a. This is correct information but not priority.
b. Heat will help promote comfort but safety of the eye is higher priority.
c. Client may have difficulty chewing on the affected side, so soft diet is encouraged, but not priority teaching.

Question 55

Which assessment data would make the nurse suspect that the client with a C7 spinal cord injury is experiencing autonomic dysreflexia?

a. Abnormal diaphoresis.
b. A severe throbbing headache.
c. Sudden loss of motor function.
d. Spastic skeletal muscle movement.

Answer 55

b. A severe throbbing headache.

A throbbing headache is the classic sign of autonomic dysreflexia, which is caused by a stimulus such as a full bladder.

Question 56

The client with an L4 spinal cord injury is admitted to the emergency department complaining of a severe pounding headache. Which intervention should the emergency nurse implement?

a. Assess the client’s vital signs.
b. Dim the lights in the room.
c. Assess for bladder distention.
d. Administer a nonnarcotic analgesic.

Answer 56

a. Assess the client’s vital signs.

The nurse should first assess the client’s vital signs to determine if the client’s blood pressure is elevated. The client with a T6 or above SCI may have autonomic dysreflexia, which would require assessing the bladder, but the client has an L4 SCI so this intervention should not be appropriate.