Unit 4 SCI/GBS Flashcards
Which interventions are indicated to treat the loss of vasomotor tone in the patient with an acute SCI?
SATA
A. Positive inotropes
B. Corticosteroids
C. Antispasmodics
D. IV fluids
E. Vasopressors
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A. Positive inotropes
D. IV fluids
E. Vasopressors
Which action is the highest priority in the patient who present with autonomic dysreflexia?
A. Prepare for intubation
B. Initiate vasopressors
C. Remove the stimulus
D. Place temporary pacemaker
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C. Remove the stimulus
What pathophysiological process occur in the first stage or acute phase of GBS?
A. Peripheral nerve demyelination, edema, and inflammation
B. Depolarization of the spinal nerves
C. Destruction of the myelin-producing oligodendrocytes
D. Regeneration of the myelin sheath
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A. Peripheral nerve demyelination, edema, and inflammation
The nurse correlates respiratory compromise in GBS with which pathophysiological process?
A. Decreased protein in the CSF
B. Progressive Limb weakness
C. Diaphragmatic weakness
D. Decreased acetylcholine at the neuromuscular junction
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C. Diaphragmatic weakness
Which nursing intervention is a priority for a patient with cranial nerve impairment from GBS ?
A. Perform sensory checks with the Nuerological examination below the level of cervical spine
B. Consult with the provider for initiation of continuous positive airway pressure for breathing
C. Creating turning Schedule with limited time in the side lying position
D. Establish effective communication using eye blinks or communication board
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D. Establish effective communication using eye blinks or communication board
The nurse understands that which Hemodynamic parameters are consistent with hypovolemic shock ?
A. Decreased CO , deceased SVR, decreased CVP
B. Decreased CO, increased SVR, decreased CVP
C. Decreased CO, increased SVR, increased CVP
D. Decreased CO, decreased SVR, increased CVP
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B. Decreased CO, increased SVR, decreased CVP
The nurse correlates which of the following hemodynamic parameters to the patient with cardiogenic shock ?
A. Decreased afterload
B. Increased contractility
C. Increased cardiac output
D. Increased Right atrial pressure
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D. Increased Right atrial pressure
The nurse understands that which of the following are manifestations of neurogenic shock? SATA
A. Tachycardia
B. Vasoconstriction
C. Tachypnea
D. Decreased CVP
E. Bradycardia
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D. Decreased CVP
E. Bradycardia
An older adult patient was admitted to the hospital 1 hr ago with a urinary tract infection,fever , tachycardia, hypotension, and confusion. The nurse anticipated which of the following interventions ?
A. Assess fluid status, insert arterial line , insert central venous lines
B. Initiate vasoactive drip, obtain lactate level, and blood cultures
C. Obtain blood and urine culture, initiate broad spectrum antibiotics , fluid resuscitation
D. Assess fluid status, obtain lactate level, insert central venous catheter
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C. Obtain blood and urine culture, initiate broad spectrum antibiotics , fluid resuscitation
A nurse is planning care for a client who has a spinal cord injury involving the T-12 fracture 1 week ago. The client has no muscle muscle control of the lower limbs , bowel or bladder. Which of the following should be the nurses highest 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
A nurse is caring for a client who has a SCI who reports severe headache and is sweating profusely. Vital signs include blood pressure of 220/110 and HR of 54/min. Which of the following actions should the nurse take first ?
A. Examine skin for irritation or pressure
B. Sit the client upright in the bed
C. Check for urinary catheter for blockage
D. Administer anti hypertensive medications
B. Sit the client upright in the bed
A nurse is caring for a client who has a C4 SCI. The nurse should recognize the client is at greatest risk for which of the following complications?
A. Neurogenic shock
B. Paralytic ileus
C. Stress ulcer
D. Respiratory compromise
D. Respiratory compromise
A nurse is caring for a client who experienced a cervical spine injury 24 hrs ago. Which of the following prescriptions should the nurse clarify with the provider ?
A. Anticoagulant
B. Plasma expanders
C. H2 antagonist
D. Muscle relaxants
D. Muscle relaxants
A nurse is caring for a client who experienced a cervical spine injury 3 months ago. The nurse should plan to implement which of the following types of bladder management methods?
A. Condom catheter
B. Intermittent urinary catheterization
C. Credes method
D. Indwelling urinary catheter
A. Condom catheter
A client with a SCI is prone to experiencing autonomic dysreflexia. The nurse should include which measures in the plan of care to minimize the risk of occurrence ? SATA
A. Keeping the linens wrinkle free under the client
B. Preventing unnecessary pressure on the lower limbs
C. Limiting bladder catheterization to once every 12 hrs
D. Turning and repositioning the client at least every 2 hours
E. Ensuring that the client has a bowel movement at least once a week
A. Keeping the linens wrinkle free under the client
B. Preventing unnecessary pressure on the lower limbs
D. Turning and repositioning the client at least every 2 hours
The nurse is assessing the motor and sensory function of an unconscious patient. The nurse should use which technique to test the clients peripheral response to pain ?
A. Sternal rub
B. Nail bed pressure
C. Pressure to the orbital rim
D. Squeezing of the sternocleidomastoid muscle
B. Nail bed pressure
The nurse is evaluating the neurological signs of a client in spinal shock following spinal cord injury which observations indicates that the spinal shock persists ?
A. Hyperreflexia
B. Positive reflexes
C. Flaccid paralysis
D. Reflex emptying of the bladder
C. Flaccid paralysis
The client is admitted to the hospital with a diagnosis of GBS. Which past medical history findings makes the client most at risk for this disease?
A. Meningitis or encephalitis during the last 5 years
B. Seizures or trauma to the brain within the last year
C. Back injury or trauma to the spinal cord during the last 2 years
D. Respiratory or GI infection during the previous month
D. Respiratory or GI infection during the previous month
A client with GBS has ascending paralysis and is intubated and receiving mechanical ventilation. Which strategy should the nurse incorporate in the plan of care to help the client cope with this illness ?
A. Giving client full control over care decision and restricting visitors
B. Providing positive feedback and encouraging active range of motion
C. Providing information, giving positive feedback and encouraging relaxation
D. Providing intravenously administered sedatives , reducing distractions, and limiting visitors
C. Providing information, giving positive feedback and encouraging relaxation
A client has a neurological deficit involving the limbic system. On assessment which finding is specific to this type of deficit ?
A. Is disoriented to person, place and time
B. Affect is flat with periods of emotional lability
C. Cannot recall what was eaten for breakfast today
D. Demonstrates inability to add and subtract ; does not know who is the president of the US
B. Affect is flat with periods of emotional lability
The nurse has completed discharge instructions for a client with application of a halo device. Which statement indicates that the client needs further clarification of the instructions ?
A. I will use a straw for drinking
B. I will drive only during the daytime
C. I will be careful because the device alters balance
D. I will wash the skin daily under the lambs wool liner of the vest
B. I will drive only during the daytime
The nurse is admitting a client with GBS to the nursing unit. The client has ascending paralysis tot eh level of the waist. Knowing the complications of the disorder the nurse should bring which most essential items into the clients room ?
A. Nebulizer and pulse oximeter
B. Blood pressure cuff and flashlight
C. Flashlight and incentive spirometer
D. Electrocardiographic monitoring electrodes and intubation tray
D. Electrocardiographic monitoring electrodes and intubation tray
What are the priority interventions for autonomic dysreflexia ?????
- Raise HOB and notify PCP
- Loosen tight clothing on client
- Check for bladder distention or other noxious stimulus
- Administer anti hypertensive
- Document occurrence and response
Flaccid paralysis
Loss of reflex activity below the level of injury
Bradycardia
Hypotension
Paralytic ileus
Are all S/S of what shock ?
Spinal shock
Hypotension
Bradycardia
Decreased UO
Decreased CO, SVR O2
Warm dry flushed skin
Are s/s of what shock ?
Neurogenic shock
Sudden severe HA
Severe HTN
Bradycardia
Flushing above the level of injury
Pale extremities below the level of injury
Nasal stuffiness
Dilated pupils or blurred vision
Sweating
Piloerection
Restlessness
Are all signs of what complication associated with SCI??
Autonomic dysreflexia
The nurse is evaluating a client in a skeletal traction,. When evaluating the pin sites , the nurse would be most concerned with which findings ?
A. Redness around the pin sites
B. Pain on palpitation at the pin sites
C. Thick, yellow drainage from the pin sites
D. Clear , watery drainage from the pin sites
C. Thick, yellow drainage from the pin sites
