Unit 4 SCI/GBS

Question 1

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

37.5

Answer 1

A. Positive inotropes
D. IV fluids
E. Vasopressors

Question 2

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

37.6

Answer 2

C. Remove the stimulus

Question 3

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

38.6

Answer 3

A. Peripheral nerve demyelination, edema, and inflammation

Question 4

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

38.7

Answer 4

C. Diaphragmatic weakness

Question 5

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

38.8

Answer 5

D. Establish effective communication using eye blinks or communication board

Question 6

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

14.5

Answer 6

B. Decreased CO, increased SVR, decreased CVP

Question 7

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

14.6

Answer 7

D. Increased Right atrial pressure

Question 8

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

14.7

Answer 8

D. Decreased CVP
E. Bradycardia

Question 9

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

14.8

Answer 9

C. Obtain blood and urine culture, initiate broad spectrum antibiotics , fluid resuscitation

Question 10

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

Answer 10

A. Prevention of further damage to the spinal cord

Question 11

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

Answer 11

B. Sit the client upright in the bed

Question 12

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

Answer 12

D. Respiratory compromise

Question 13

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

Answer 13

D. Muscle relaxants

Question 14

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

Answer 14

A. Condom catheter

Question 15

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

Answer 15

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

Question 16

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

Answer 16

B. Nail bed pressure

Question 17

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

Answer 17

C. Flaccid paralysis

Question 18

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

Answer 18

D. Respiratory or GI infection during the previous month

Question 19

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

Answer 19

C. Providing information, giving positive feedback and encouraging relaxation

Question 20

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

Answer 20

B. Affect is flat with periods of emotional lability

Question 21

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

Answer 21

B. I will drive only during the daytime

Question 22

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

Answer 22

D. Electrocardiographic monitoring electrodes and intubation tray

Question 23

What are the priority interventions for autonomic dysreflexia ?????

Answer 23

1. Raise HOB and notify PCP
2. Loosen tight clothing on client
3. Check for bladder distention or other noxious stimulus
4. Administer anti hypertensive
5. Document occurrence and response

Question 24

Flaccid paralysis
Loss of reflex activity below the level of injury
Bradycardia
Hypotension
Paralytic ileus

Are all S/S of what shock ?

Answer 24

Spinal shock

Question 25

Hypotension
Bradycardia
Decreased UO
Decreased CO, SVR O2
Warm dry flushed skin

Are s/s of what shock ?

Answer 25

Neurogenic shock

Question 26

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??

Answer 26

Autonomic dysreflexia

Question 27

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

Answer 27

C. Thick, yellow drainage from the pin sites