Deck 61: Nursing Management: Peripheral Nerve and Spinal Cord Problems

Question 1

A patient with Bell's palsy refuses to eat while others are present because of embarrassment about drooling. The best response by the nurse to the patient's behavior is to

A) respect the patient's desire 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.

Answer 1

respect the patient's desire and arrange for privacy at mealtimes.

Question 2

When the nurse is developing a rehabilitation plan for a patient with a C6 spinal cord injury, an appropriate patient goal is that the patient will be able to

A) transfer independently to a wheelchair.
B) drive a car with powered hand controls.
C) turn and reposition independently when in bed.
D) push a manual wheelchair on flat, smooth surfaces.

Answer 2

push a manual wheelchair on flat, smooth surfaces.

Question 3

When teaching patients who are at risk for Bell's palsy because of previous herpes simplex infection, which information should the nurse include?

A) "Call the doctor if pain or herpes lesions occur near the ear."
B) "Treatment of herpes with antiviral agents prevents Bell's palsy."
C) "You may be able to prevent Bell's palsy by doing facial exercises regularly."
D) "Medications to treat Bell's palsy work only if started before paralysis onset."

Answer 3

"Call the doctor if pain or herpes lesions occur near the ear."

Question 4

Which action should the nurse take when assessing a patient with trigeminal neuralgia?

A) Examine the mouth and teeth thoroughly.
B) Have the patient clench and relax the jaw and eyes.
C) Identify trigger zones by lightly touching the affected side.
D) Gently palpate the face to compare skin temperature bilaterally.

Question 5

Which nursing action will the home health nurse include in the plan of care for a patient with paraplegia in order to prevent autonomic dysreflexia?

A) Assist with selection of a high protein diet.
B) Use quad coughing to assist cough effort.
C) Discuss options for sexuality and fertility.
D) Teach the purpose of a prescribed bowel program.

Question 6

A patient with a T1 spinal cord injury is admitted to the intensive care unit. The nurse will teach the patient and family that

A) use of the shoulders will be preserved.
B) full function of the patient's arms will be retained.
C) total loss of respiratory function may occur temporarily.
D) elevations in heart rate are common with this type of injury.

Question 7

A patient who sustained a spinal cord injury a week ago becomes angry, telling the nurse "I want to be transferred to a hospital where the nurses know what they are doing!" Which reaction by the nurse is best?

A) Ask for the patient's input into the plan for care.
B) Clarify that abusive behavior will not be tolerated.
C) Reassure the patient about the competence of the nursing staff.
D) Continue to perform care without responding to the patient's comments.

Question 8

The health care provider prescribes these interventions for a patient with possible botulism poisoning. Which one will the nurse question?

A) Maintain NPO status.
B) Obtain lumbar puncture tray.
C) Give magnesium citrate 8 oz now.
D) Administer 1500-mL tap water enema.

Question 9

When caring for a patient who has Guillain-Barré syndrome, which assessment data obtained by the nurse will require the most immediate action?

A) The patient has continuous drooling of saliva.
B) The patient's blood pressure (BP) is 106/50 mm Hg.
C) The patient's quadriceps and triceps reflexes are absent.
D) The patient complains of severe tingling pain in the feet.

Question 10

When assessing a patient with newly diagnosed trigeminal neuralgia, the nurse will ask the patient about

A) triggers that lead to facial pain.
B) visual problems caused by ptosis.
C) poor appetite caused by a loss of taste.
D) weakness on the affected side of the face.

Question 11

When evaluating a patient with trigeminal neuralgia who has had a glycerol rhizotomy, the nurse will

A) ask whether the patient is using an eye shield at night.
B) determine whether the patient is doing daily facial exercises.
C) question the patient about social activities with family and friends.
D) remind the patient to chew food on the unaffected side of the mouth.

Question 12

A patient with a neck fracture at the C5 level is admitted to the intensive care unit. During initial assessment of the patient, the nurse recognizes the presence of neurogenic shock on finding

A) hypotension, bradycardia, and warm extremities.
B) involuntary, spastic movements of the arms and legs.
C) hyperactive reflex activity below the level of the injury.
D) lack of movement or sensation below the level of the injury.

Question 13

A patient arrives at an urgent care center with a deep puncture wound after stepping on a nail that was lying on the ground. The patient reports having had a tetanus booster 7 years ago. The nurse will 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.

Question 14

Which action will the nurse include in the plan of care when caring for a patient who is experiencing trigeminal neuralgia?

A) Teach facial and jaw relaxation techniques.
B) Assess intake and output and dietary intake.
C) Apply ice packs for no more than 20 minutes.
D) Spend time at the bedside talking with the patient.

Question 15

A 24-year-old patient is hospitalized with the onset of Guillain-Barré syndrome. During this phase of the patient's illness, the most essential assessment for the nurse to carry out is

A) monitoring the cardiac rhythm.
B) determining level of consciousness.
C) checking strength of the extremities.
D) observing respiratory rate and effort.

Question 16

A patient has an incomplete right 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 left leg pain
B) Assessment of the patient for left arm weakness
C) Positioning the patient's right leg when turning the patient
D) Teaching the patient to look at the left leg to verify its position

Question 17

A patient who has numbness and weakness of both feet is hospitalized with Guillain-Barré syndrome. The nurse will anticipate the need to teach the patient about

A) intubation and mechanical ventilation.
B) administration of IV corticosteroid drugs.
C) insertion of a nasogastric (NG) feeding tube.
D) IV infusion of immunoglobulin (Sandoglobulin).

Question 18

After a 25-year-old patient has returned home following rehabilitation for a spinal cord injury, the home care nurse notes that the spouse is performing many of the activities that the patient had been managing during rehabilitation. The most appropriate action by the nurse at this time is to

A) tell the spouse that the patient can perform activities independently.
B) remind the patient about the importance of independence in daily activities.
C) develop a plan to increase the patient's independence in consultation with the patient and the spouse.
D) recognize that it is important for the spouse to be involved in the patient's care and support the spouse's participation.

Question 19

When caring for a patient who was admitted 24 hours previously with a C5 spinal cord injury, which nursing action has the highest priority?

A) Assessment of respiratory rate and depth
B) Continuous cardiac monitoring for bradycardia
C) Application of pneumatic compression devices to both legs
D) Administration of methylprednisolone (Solu-Medrol) infusion

Question 20

A patient with paraplegia resulting from a T10 spinal cord injury has a neurogenic reflex bladder. Which action will the nurse include in the plan of care?

A) Educate on the use of the Credé method.
B) Teach the patient how to self-catheterize.
C) Catheterize for residual urine after voiding.
D) Assist the patient to the toilet every 2 hours.

Question 21

A patient admitted to the emergency department is diagnosed with botulism, and an order for botulinum antitoxin is received. Before administering the antitoxin, it is most important for the nurse to

A) obtain the patient's temperature.
B) administer an intradermal test dose.
C) ask the patient about a history of egg allergies.
D) document the presence of neurologic symptoms.

Question 22

When caring for a patient who experienced a T₁ spinal cord transsection 2 days ago, which collaborative and nursing actions will the nurse include in the plan of care (select all that apply)?

A) Urinary catheter care
B) Nasogastric (NG) tube feeding
C) Continuous cardiac monitoring
D) Avoidance of cool room temperature
E) Administration of H₂ receptor blockers

Question 23

A 26-year-old patient with a T₃ spinal cord injury asks the nurse about whether he will be able to be sexually active. Which initial response by the nurse is best?

A) Reflex erections frequently occur, but orgasm may not be possible.
B) Sildenafil ( Viagra ) is used by many patients with spinal cord injury.
C) Multiple options are available to maintain sexuality after spinal cord injury.
D) Penile injection, prostheses, or vacuum suction devices are possible options.

Question 24

Which of these nursing actions for a patient with Guillain-Barré syndrome is most appropriate for the nurse to delegate to an experienced nursing assistant?

A) Nasogastric tube feeding q4hr
B) Artificial tear administration q2hr
C) Assessment for bladder distention q2hr
D) Passive range of motion to extremities q8hr

Question 25

To evaluate the effectiveness of IV methylprednisolone (Solu-Medrol) given to a patient with a T₄ spinal cord injury, which information is most important for the nurse to obtain?

A) Leg strength and sensation
B) Skin temperature and color
C) Blood pressure and apical heart rate
D) Respiratory effort and O₂ saturation

Question 26

A patient with a history of a T2 spinal cord injury tells the nurse, "I feel awful today. My head is throbbing, and I feel sick to my stomach." Which action should the nurse take first?

A) Assess for a fecal impaction.
B) Give the prescribed antiemetic.
C) Check the blood pressure (BP).
D) Notify the health care provider.

Question 27

When caring for a patient who had a C8 spinal cord injury 10 days ago and has a weak cough effort and loose-sounding secretions, the initial intervention by the nurse should be to

A) suction the patient's oral and pharyngeal airway.
B) administer oxygen at 7 to 9 L/min with a face mask.
C) place the hands on the epigastric area and push upward when the patient coughs.
D) encourage the patient to use an incentive spirometer every 2 hours during the day.

Question 28

In which order will the nurse perform the following actions when caring for a patient with possible C6 spinal cord trauma who is admitted to the emergency department? Put a comma and space between each solve choice (a, b, c, d, etc.) ____________________

A) Infuse normal saline at 150 mL/hr.
B) Monitor cardiac rhythm and blood pressure.
C) Administer O₂ using a non-rebreather mask.
D) Transfer the patient to radiology for spinal computed tomography ( CT ).
E) Immobilize the patient's head, neck, and spine.

Question 29

The nurse is assessing a patient who is being evaluated for a possible spinal cord tumor. Which finding by the nurse requires the most immediate action?

A) The patient has new onset weakness of both legs.
B) The patient complains of chronic severe back pain.
C) The patient starts to cry and says, "I feel hopeless."
D) The patient expresses anxiety about having surgery.