Deck 45: Care of Patients With Problems of the Central Nervous System: the Spinal Cord

Question 1

A client who has a lower motor neuron injury experiences a flaccid bowel elimination pattern.Which action does the nurse implement to assist in relieving this client's constipation?

A) Pouring warm water over the perineum
B) Tapping the abdomen from left to right
C) Administering daily tap water enemas
D) Implementing a consistent daily time for elimination

Answer 1

Implementing a consistent daily time for elimination

Question 2

A client with paraplegia is scheduled to participate in a rehabilitation program.The client states,"I do not understand the need for rehabilitation; the paralysis will not go away and it will not get better." How does the nurse respond?

A) "If you do not want to participate in the rehabilitation program, I will cancel the order."
B) "Your doctor has helped many clients with your injury and has ordered a rehabilitation program to help you."
C) "The rehabilitation program will teach you how to maintain the functional ability you have and prevent further disability."
D) "When new discoveries are made regarding paraplegia, people in rehabilitation programs will benefit first."

Answer 2

"The rehabilitation program will teach you how to maintain the functional ability you have and prevent further disability."

Question 3

Emergency medical services arrive to the emergency department with a client who has a cervical spinal cord injury.Which priority assessment does the emergency department nurse perform at this time?

A) Level of consciousness and orientation
B) Heart rate and rhythm
C) Muscle strength and reflexes
D) Respiratory pattern and airway

Answer 3

Respiratory pattern and airway

Question 4

A client presents with an acute exacerbation of multiple sclerosis.Which prescribed medication does the nurse prepare to administer?

A) Baclofen (Lioresal)
B) Interferon beta-1b (Betaseron)
C) Dantrolene sodium (Dantrium)
D) Methylprednisolone (Medrol)

Question 5

The nurse is assessing a client with an early onset of multiple sclerosis (MS).Which clinical manifestation does the nurse expect to see?

A) Hyperresponsive reflexes
B) Excessive somnolence
C) Nystagmus
D) Heat intolerance

Question 6

A client who has a herniated disk is being discharged after a percutaneous endoscopic discectomy.Which postprocedure instructions does the nurse provide before discharge?

A) "You should begin an exercise routine which includes walking every day."
B) "You must sleep in a supine position until the bandage is removed."
C) "You may feel numbness or tingling in the legs for 24 hours."
D) "You will need to wear a lumbar brace for 1 week."

Question 7

The nurse assesses for which clinical manifestation in a client with multiple sclerosis (MS)of the relapsing type?

A) Absence of periods of remission
B) Attacks becoming increasingly frequent
C) Absence of active disease manifestations
D) Gradual neurologic symptoms without remission

Question 8

The nurse is caring for a client who has undergone a spinal fusion.Which specific postoperative instructions does the nurse give this client?

A) "You may lift items up to 10 pounds."
B) "Wear your brace when you are out of bed."
C) "You must remain on bedrest for 48 hours after surgery."
D) "You will need to take steroids to prevent rejection of the bone graft."

Question 9

The nurse notes reddened areas over the hips and sacrum of a client with paraplegia from a spinal cord injury.Which action does the nurse implement?

A) Massage the reddened areas with a barrier cream.
B) Perform hip flexion and extension range-of-motion (ROM) exercises.
C) Reposition the client so that the reddened area does not bear weight.
D) Ensure that the client sits in a chair at least once each shift.

Question 10

The nurse is teaching a client who has a spinal cord injury how to prevent respiratory problems at home.Which statement indicates that the client correctly understands the teaching?

A) "I will use my incentive spirometer every 2 hours while I'm awake."
B) "I will not drink thick fluids to prevent choking."
C) "I will take cough medicine to prevent excessive coughing."
D) "I will position myself on my right side so I don't aspirate."

Question 11

A client who suffered a spinal cord injury at level T5 several months ago develops a flushed face and blurred vision.On taking vital signs,the nurse notes the blood pressure to be 184/95 mm Hg.Which is the nurse's first action?

A) Palpate the area over the bladder for distention.
B) Place the client in the Trendelenburg position.
C) Administer oxygen via a nasal cannula.
D) Perform bilateral carotid massage.

Question 12

The nurse is assessing a client who had a discectomy 6 hours ago.Which client complaint requires priority action by the nurse?

A) "I am feeling tired."
B) "My mouth is so dry."
C) "I can't seem to relax and rest."
D) "I am unable to urinate."

Question 13

The nurse is providing discharge teaching to a client after a lumbar laminectomy.For which complication does the nurse instruct the client to return to the hospital?

A) Pain at the incision site
B) Decreased appetite
C) Slight redness and itching at the incision site
D) Clear drainage from the incision site

Question 14

The nurse is caring for a client who has low back pain (LBP)from a work-related injury.Which measures does the nurse incorporate into the client's plan of care?

A) Apply moist heat continuously to the affected area.
B) Use ice packs or ice massage for 1 to 2 hours over the affected area.
C) Apply heat packs for 20 to 30 minutes at least four times daily.
D) Advise the client to avoid hot baths or showers.

Question 15

The nurse is caring for a client who has a vertebral fracture.Which intervention does the nurse implement to prevent deterioration of the client's neurologic status?

A) Reorient the client to time, place, and person.
B) Administer the Mini-Mental State Examination.
C) Immobilize the affected portion of the spinal column.
D) Reposition the client every 2 hours.

Question 16

The nurse is providing health education at a community center.Which instruction does the nurse include as part of client education for the prevention of low back pain?

A) "Participate in a regular exercise program."
B) "Purchase a soft mattress for sleeping comfort."
C) "Wear high-heeled shoes only for special occasions."
D) "Keep your weight within 20% of your ideal body weight."

Question 17

A client with multiple sclerosis is being treated with fingolimod (Gilenya).Which clinical manifestation alerts the nurse to an adverse effect of this medication?

A) Periorbital edema
B) Black tarry stools
C) Bradycardia
D) Vomiting after meals

Question 18

The nurse is assessing a client with a spinal cord injury at the T5 level.Which clinical manifestation alerts the nurse to the presence of a complication of this injury?

A) Rhinorrhea and epiphora
B) Fever and cough
C) Agitation and restlessness
D) Hip and knee pain

Question 19

A client who experienced a spinal cord injury 1 hour ago is brought to the emergency department.Which prescribed medication does the nurse prepare to administer to this client?

A) Intrathecal baclofen (Lioresal)
B) Methylprednisolone (Medrol)
C) Atropine sulfate
D) Epinephrine (Adrenalin)

Question 20

The nurse is caring for a client with a lower motor neuron lesion who wishes to achieve bladder control.Which intervention does the nurse implement to effectively stimulate the initiation of voiding for this client?

A) Stroking the inner aspect of the thigh
B) Intermittent catheterization
C) Digital anal stimulation
D) The Valsalva maneuver

Question 21

Which neurologic test or procedure requires the nurse to determine whether an informed consent has been obtained from the client before the test or procedure?

A) Measurement of sensation using the pinprick method
B) Computed tomography of the cranial vault
C) Lumbar puncture for cerebrospinal fluid (CSF) sampling
D) Venipuncture for autoantibody analysis

Question 22

The nurse is teaching a client with a spinal cord tumor about the treatment plan.Which statements indicate that the client correctly understands the teaching?

A) "Because my symptoms occurred so quickly, I am likely to be cured quickly by surgery."
B) "Radiation therapy can shrink the tumor but radiation can cause more problems, too."
C) "I am glad you are here to turn me. Lying in one position for a long time makes my pain worse, even if turning is uncomfortable."
D) "I have put my affairs in order and purchased a burial plot because this type of cancer is almost always fatal."
E) "My family is making some changes at home for me, including moving my bedroom downstairs."

Question 23

The nurse is planning care for a client who has a spinal cord injury.Which interdisciplinary team member does the nurse consult with to assist the client with activities of daily living?

A) Social worker
B) Physical therapist
C) Occupational therapist
D) Case manager

Question 24

The nurse is teaching a client who has an unstable thoracic vertebral fracture and is being treated with immobilization before surgery.Which statement does the nurse include in the client's teaching?

A) "You will need to apply an immobilizing brace snugly around your waist when out of bed."
B) "You will remain strapped to the transport back board until the surgical room is ready."
C) "Keep your spine in alignment by not sitting up, arching your back, or twisting in bed."
D) "An incentive spirometer will prevent you from having atelectasis and pneumonia after surgery."

Question 25

The nurse is preparing a client who has multiple sclerosis (MS)for discharge home from a rehabilitation center.The client has been prescribed cyclophosphamide (Cytoxan)and methylprednisolone (Medrol).Which instruction does the nurse include in the teaching plan for the client?

A) "Take warm baths to promote muscle relaxation."
B) "Avoid crowds and people with colds."
C) "Use physical aids such as walkers as little as possible."
D) "Stop using these medications when your symptoms improve."

Question 26

A client is scheduled for magnetic resonance imaging (MRI).Which action does the nurse implement before the test?

A) Ensure that the person does not eat for 8 hours before the procedure.
B) Discontinue all neuroactive medications 3 hours before the procedure.
C) Make sure that the client has an identification bracelet that cannot be removed.
D) Replace the client's gown with metal snaps with one that has cloth ties.

Question 27

The nurse is discussing advanced directives with a client who has amyotrophic lateral sclerosis (ALS).The client states,"I do not want to be placed on a mechanical ventilator." How does the nurse respond?

A) "You will need to discuss that with your family and health care provider."
B) "Why are you afraid of being placed on a breathing machine?"
C) "What would you like to be done if you begin to have difficulty breathing?"
D) "You will be on the ventilator only until your muscles get stronger."

Question 28

Early manifestations of amyotrophic lateral sclerosis (ALS)and multiple sclerosis (MS)are somewhat similar.Which clinical feature of ALS distinguishes it from MS?

A) Dysarthria
B) Dysphagia
C) Muscle weakness
D) Impairment of respiratory muscles

Question 29

The nurse is assessing a client's coping strategies after suffering a traumatic spinal cord injury.Which information related to this assessment is important for the nurse to obtain?

A) Spiritual or religious beliefs
B) Level of pain
C) Family support
D) Level of independence
E) Annual income
F) Previous coping strategies

Question 30

The nurse is teaching a male client with a spinal cord injury at T4 (thoracic)about the sexual effects of this injury.Which statement by the client indicates correct understanding of the teaching?

A) "I will not be able to have an erection because of my injury."
B) "Ejaculation may not be as predictable as before."
C) "I will explore other ways besides intercourse to please my partner."
D) "I may urinate with ejaculation but this will not cause an infection."
E) "I should be able to have an erection with stimulation."