Porth (2020) 5th nur 317 Flashcards
Chapter 15
After being thrown off the back of a bull, a bull rider can move his arms but has loss of motor function in the lumbar and sacral segments of the spinal cord. This is referred to as:
Anterior cord syndrome
Quadriplegia
Paraplegia
Tetraplegia
Paraplegia
Rationale:Tetraplegia and quadriplegia are loss of motor or sensory function after damage to neural structures in the cervical segments of the spinal cord. Paraplegia refers to loss of motor or sensory function in thoracic, lumbar, or sacral segments. The arms function as normal. Anterior cord syndrome includes loss of motor function provided by the corticospinal tracts and loss of pain and temperature sensation from damage to the lateral spinothalamic tracts.
The nurse is assessing a client diagnosed with myasthenia gravis (MG). The nurse would expect the assessment to include:
Loss of hearing on the affected side
Inability to move eyes in multiple positions
Impaired ability to move tongue laterally
Absent deep tendon reflexes
Inability to move eyes in multiple positions
Rationale:Commonly affected are the eye and periorbital muscles, with ptosis (drooping of eyelids) due to eyelid weakness or diplopia (double vision) due to weakness of the extraocular muscles as an initial symptom. The disease may progress from ocular muscle weakness to generalized weakness, including respiratory muscle weakness. Chewing and swallowing may be difficult. Weakness in limb movement usually is more pronounced in the proximal rather than distal parts of the extremity. Speech may be impaired.
Select the laboratory blood test that would be a used to suggest a diagnosis of muscular dystrophy (MD).
Creatine kinase
Amylase levels
Serum glucose
Rheumatoid factor
Creatine kinase
Rationale:Serum levels of the enzyme creatine kinase (CK), which leaks out of damaged muscle fibers, suggest the presence of the disease. A muscle biopsy, which shows a mixture of muscle cell degeneration and regeneration and reveals fat and scar tissue replacement, may be done to confirm the diagnosis.
Following his annual influenza vaccination, a client begins to feel achy, like he has developed the flu. An hour later, the client is rushed to the emergency department and diagnosed of Guillain-Barré syndrome based on which assessment findings? Select all that apply.
Pale, cool, dry skin
BP 90/62
Rapid deterioration of respiratory status
Flaccid paralysis of limbs
Lack of any physical pain
BP 90/62,
Rapid deterioration of respiratory status,
Flaccid paralysis of limbs
Rationale:Guillain-Barré syndrome usually is a medical emergency. There may be a rapid development of ventilatory failure and autonomic disturbances that threaten circulatory function. The disorder is characterized by progressive ascending muscle weakness of the limbs, producing a symmetric flaccid paralysis. Paralysis may progress to involve the respiratory muscles. Autonomic nervous system involvement that causes postural hypotension, dysrhythmias, facial flushing, abnormalities of sweating, and urinary retention is common. Pain is another common feature of Guillain-Barré syndrome.
A recently injured (3 months ago) client with a spinal cord injury at T4 to T5 is experiencing a complication. He looks extremely ill. The nurse recognizes this as autonomic dysreflexia (autonomic hyperreflexia). His BP is 210/108; skin very pale; gooseflesh noted on arms. The priority nursing intervention would be to:
assess calves of legs for redness, warmth, or edema.
check the mouth/throat for pustules and redness.
check the jugular vein for distention.
scan his bladder to make sure it is empty.
scan his bladder to make sure it is empty.
Rationale:Autonomic hyperreflexia, an acute episode of exaggerated sympathetic reflex responses that occur in persons with injuries at T6 and above, in which central nervous system (CNS) control of spinal reflexes is lost, does not occur until spinal shock has resolved and autonomic reflexes return. Autonomic dysreflexia is characterized by vasospasm, hypertension ranging from mild to severe, skin pallor, and gooseflesh associated with the piloerector response. In many cases, the dysreflexic response results from a full bladder. There is no indication the client has right-sided heart failure (jugular vein distention); has a DVT (calf redness, warmth, or edema); or has strep throat (pustules and red throat/tonsils).
Which complication of spinal cord injury is the most preventable in a paraplegic client?
Autonomic dysreflexia
Deep vein thrombosis
Muscle atrophy
Skin breakdown
Which complication of spinal cord injury is the most preventable in a paraplegic client?
Autonomic dysreflexia
Deep vein thrombosis
Muscle atrophy
Skin breakdown
In what part of the body does the highest level of motor function occur?
Brain stem
Brain’s cerebellum
Spinal cord
Frontal cortex of the brain
Frontal cortex of the brain
Rationale:The highest level of function, which occurs at the level of the frontal cortex, is concerned with the purpose and planning of the motor movement. The efficiency of movement depends on input from sensory systems that operate in parallel with the motor systems. The other options are responsible for lower-level functions
A client is devastated to receive a diagnosis of amyotrophic lateral sclerosis (ALS). The symptomatology of this disease is a result of its effects on upper and lower motor neurons. The health care provider caring for this client will focus on which priority intervention for this client?
Ability to empty bladder completely, thereby preventing autonomic dysreflexia
Ability to turn from side to side, thereby preventing skin breakdown
Assessment of lower extremities to prevent deep vein thrombosis
Respiratory ventilation assessment and prevention of aspiration pneumonia
Respiratory ventilation assessment and prevention of aspiration pneumonia
Rationale:Amyotrophic lateral sclerosis is a mixed upper motor neuron (UMN) and lower motor neuron (LMN) disorder. In the more advanced stages of ALS, muscles of the palate, pharynx, tongue, neck, and shoulders become involved, causing impairment of chewing, swallowing (dysphagia), and speech. Dysphagia with recurrent aspiration and weakness of the respiratory muscles produces the most significant acute complications of the disease. Airway/breathing is always the priority over bladder emptying, skin breakdown, and assessing for DVT.
Which symptom is unique to amyotrophic lateral sclerosis (ALS) and is not observed in multiple sclerosis (MS)?
Respiratory muscle impairment
Dysarthria
Fatigue
Optic nerve dysfunction
Respiratory muscle impairment
Rationale:Dysphagia with recurrent aspiration and weakness of the respiratory muscles produce the most significant acute complication of ALS. MS does not typically include respiratory muscle impairment.
When assessing the motor system, which area of the assessment should be the focus for the nurse? Select all that apply.
Coordination
Presence of involuntary muscle movement
Presence of muscle pain
Body position
Muscle strength
Coordination,
Presence of involuntary muscle movement,
Body position,
Muscle strength
Rationale:Assessing the motor system should include assessment of body position, involuntary movements, muscle characteristics (strength, bulk, and tone), spinal reflexes, and coordination. Muscle pain is not included in this assessment of motor function.
The nurse is teaching a client about appropriate interventions for back pain. Select all that apply.
Bed rest
Aerobic exercise
Analgesics
Nonsteroidal anti-inflammatory drugs
Muscle relaxants
Analgesics,
Nonsteroidal anti-inflammatory drugs,
Muscle relaxants
Rationale:Treatment of back pain usually is conservative and consists of analgesic medications, muscle relaxants, and instruction in the correct mechanics for lifting and methods of protecting the back. Pain relief is usually provided using nonsteroidal anti-inflammatory drugs. Bed rest, once the mainstay of conservative therapy, is now understood to be ineffective for acute back pain. Conditioning exercises of the trunk muscles, particularly the back extensors, are often recommended.
A sudden, traumatic, complete transection of the spinal cord results in what type of injury below the site?
Deep visceral pain
Vasoconstriction
3+ tendon reflexes
Flaccid paralysis
Flaccid paralysis
Rationale:Sudden, complete transection of the spinal cord results in complete loss of motor, sensory, reflex, and autonomic function below the level of injury. This immediate response to spinal cord injury, spinal cord shock, is characterized by flaccid paralysis with loss of tendon reflexes below the level of injury, absence of somatic and visceral sensations below the level of injury, and loss of bowel and bladder function. Loss of systemic sympathetic vasomotor tone may result in vasodilation, increased venous capacity, and hypotension. These manifestations occur regardless of whether the level of the lesion eventually will produce spastic or flaccid paralysis. In persons in whom the loss of reflexes persists, hypotension and bradycardia may become critical but manageable problems. In general, the higher the level of injury, the greater the effect.
An individual experiencing spinal cord damage (SCD) is at high risk for developing deep vein thrombosis (DVT) and pulmonary emboli (PE) due to which pathophysical cause? Select all that apply.
Impaired vasomotor tone
Stasis of blood flow
Impaired pain perception
Hypercoagulation of blood
Impaired mobility
Impaired vasomotor tone,
Stasis of blood flow,
Hypercoagulation of blood,
Impaired mobility
Rationale:People with SCI are at high risk for development of deep vein thrombosis (DVT) and pulmonary embolism. The high risk for DVT in people with acute SCI is due to immobility, decreased vasomotor tone below the level of injury, and hypercoagulability and stasis of blood flow. While a significant factor to the client’s increased risk for injury, poor pain perception would affect the ability to adequately identify such problems but not cause them.
An individual experiencing spinal cord damage (SCD) is at high risk for developing deep vein thrombosis (DVT) and pulmonary emboli (PE) due to which pathophysical cause? Select all that apply.
Impaired vasomotor tone
Stasis of blood flow
Impaired pain perception
Hypercoagulation of blood
Impaired mobility
Impaired vasomotor tone, Stasis of blood flow, Hypercoagulation of blood, Impaired mobility
Rationale:People with SCI are at high risk for development of deep vein thrombosis (DVT) and pulmonary embolism. The high risk for DVT in people with acute SCI is due to immobility, decreased vasomotor tone below the level of injury, and hypercoagulability and stasis of blood flow. While a significant factor to the client’s increased risk for injury, poor pain perception would affect the ability to adequately identify such problems but not cause them.
A client diagnosed with early multiple sclerosis (MS) will likely demonstrate which manifestations? Select all that apply.
Visual clouding
Anxiety
Bladder dysfunction
Paresthesia
Fatigue
Visual clouding,
Bladder dysfunction,
Paresthesia,
Fatigue
Rationale:Visual disturbances, paresthesias, abnormal gait (ataxia), bladder and sexual dysfunction, vertigo, nystagmus, fatigue, and speech disturbances are early signs of MS. Anxiety and depression are often seen later as a result of the changes the disease causes.
A client with an acute spinal cord injury is developing spinal shock. The nurse should perform which priority assessment?
Paresthesia of the extremities below the injury
Vasoconstriction causing hypertension
Inability to move lower extremities
Loss of tendon reflexes below the injury
Loss of tendon reflexes below the injury
Rationale:Spinal shock is characterized by flaccid paralysis, not paresthesia, with loss of tendon reflexes below the level of injury, absence of somatic and visceral sensations below the level of injury, and loss of bowel and bladder function. Loss of systemic sympathetic vasomotor tone may result in vasodilation, increased venous capacity, and hypotension. The spinal cord injury, not spinal shock, is the cause of the inability to move lower extremities.
Which treatment should take place immediately in a client experiencing autonomic dysreflexia?
Increase the client’s blood pressure to allow for adequate perfusion.
Place the client in a supine position, and increase intravenous fluids.
Position the client in upright position, and correct the initiating stimulus.
Apply binders and support hose to shunt the blood to the main organs.
Position the client in upright position, and correct the initiating stimulus.
Rationale:Autonomic dysreflexia is a clinical emergency, and requires monitoring of blood pressure while correcting the initiating stimulus (e.g., full bladder, pain). The nurse should place the client in an upright position and remove all support hose binders to promote venous pooling to help decrease an extremely elevated blood pressure. Intravenous fluids are not an immediate intervention for this condition.
Coordinated muscular movement requires proper functioning of four areas of the nervous system. Which system controls posture and balance?
The sensory system
The vestibular system
The cerebellar system
The motor system
The vestibular system
Rationale:The vestibular system is responsible for coordinated posture and balance, the cerebellar system for rhythmic movement and steady posture, the sensory system for position sense, and the motor system for muscle strength.
A client has just been diagnosed with multiple sclerosis (MS). The nurse recognizes that the client’s condition is a result of:
Degeneration of the lower cell bodies of the lower motor neurons in the gray matter
Degenerative changes in the musculoskeletal system
An immune-mediated response that is caused by the demyelinization of the myelin sheath of the white matter of the brain, spinal cord, and optic nerve
Circulating antibodies attacking the postsynaptic acetylcholine levels
An immune-mediated response that is caused by the demyelinization of the myelin sheath of the white matter of the brain, spinal cord, and optic nerve
Rationale:MS is an immune response against the components of the myelin sheath. There is a progressive demyelinization of the myelin sheath of the white matter of the brain, spinal cord, and the optic nerve. The other options do not describe MS.
Regarding the pathophysiology of Parkinson disease, which statement is true?
Failure of the cerebral cortex interferes with the use of acetylcholine.
The dopamine receptors increase from an alteration in neuronal basal ganglia.
Degeneration of the nigrostriatal dopamine neurons occurs.
Acetylcholine levels rise and inhibit voluntary movement.
Degeneration of the nigrostriatal dopamine neurons occurs.
Rationale:The primary brain abnormality found in all persons diagnosed with Parkinson disease is degeneration of the nigrostriatal dopamine neurons. Acetylcholine has no bearing on Parkinson development. There is a decrease in dopamine rather than an increase.
A client works as a data entry worker for a large company and goes to employee health with pain in the wrist/hand. The nurse suspects that it is carpal tunnel syndrome based on which assessment findings? Select all that apply.
Describes numbness/tingling in the thumb and first digit
States his forearm feels funny (paresthesia)
Precision grip weakness in the affected hand
Pain interferes with sleeping
Loss of tendon reflexes on the affected extremity
Describes numbness/tingling in the thumb and first digit,
Precision grip weakness in the affected hand,
Pain interferes with sleeping
Rationale:Carpal tunnel syndrome is a mononeuropathy with compression of the median nerve as it travels with the flexor tendons through a canal made by the carpal bones and transverse carpal ligament. Carpal tunnel syndrome is characterized by hand and wrist pain, hand or finger paresthesia, and numbness of the thumb and first 2 1/2 digits of the hand; atrophy of abductor pollicis muscle; pain interferes with sleep; and weakness in precision grip. Guillain-Barré syndrome is characterized by rapidly progressive limb weakness and loss of tendon reflexes.
