Deck 43: Nursing Care of Patients With Spinal Cord Disorders and Cns Infections

Question 1

The healthcare provider prescribes 15 mg IV of ketorolac (Toradol) for a patient who has recently undergone a spinal fusion. The nurse has a 5-milliliter (mL) ampule containing 60 mg of ketorolac. How many milliliters of ketorolac does the nurse need to withdraw from the syringe? _____ mL Calculate the exact dose.

Answer 1

1.25

Question 2

A patient with a secondary metastatic spinal cord tumor is scheduled for surgery. What should the nurse recognize as the goal of surgery for this patient?

A) complete removal of the tumor and affected spinal cord tissue
B) eradication of the tumor with excision and drainage
C) tumor excision to reduce cord compression
D) exploration to visualize the tumor and obtain a biopsy

Answer 2

tumor excision to reduce cord compression

Question 3

A patient with a spinal cord injury (SCI) is admitted to the unit and placed in traction. Which actions should the nurse include when caring for this patient?

A) modifying the traction weights as needed
B) assessing the patient's skin integrity
C) applying the traction upon admission
D) administering pain medication
E) providing passive range of motion

Answer 3

assessing the patient's skin integrity
administering pain medication
providing passive range of motion

Question 4

The nurse is caring for a patient recovering from a laminectomy. Which action should the nurse take to prevent skin breakdown in this patient?

A) by providing the patient with an air mattress
B) by placing pillows under the patient to help the patient turn
C) by teaching the patient to grasp the side rail to turn
D) by using the log roll to turn the patient to the side

Question 5

A nurse witnesses a motor vehicle accident (MVA) while off duty. Upon approaching the scene, the nurse observes a victim lying on the ground after being ejected from the vehicle. Arrange the actions the nurse should take in the correct order, starting with the first. All options must be used. Standard Text: Click and drag the options below to move them up or down.
Choice

A) Check the victim's breathing.
B) Check the victim's pulse.
C) Check the victim's airway.
D) Immobilize the spine.
E) Check for the victim's responsiveness.
F) none of the above

Question 6

While caring for a patient with a spinal cord injury (SCI), the nurse elevates the head of the bed, removes compression stockings, and continues to assess vital signs every 2 to 3 minutes while searching for the cause in order to prevent loss of consciousness or death. By practicing these interventions, the nurse is avoiding the most dangerous complication of autonomic dysreflexia, which is what condition?

A) hypoxia
B) bradycardia
C) elevated blood pressure
D) tachycardia

Question 7

A patient with a spinal cord injury was given IV dexamethasone (Decadron) after arriving in the emergency department. What assessment finding should the nurse attribute to the steroid medication?

A) hypoglycemia
B) less spinal shock
C) urinary retention
D) muscle spasms

Question 8

A hospitalized patient with a C7 cord injury yells, "I can't feel my legs anymore." Which is the most appropriate action by the nurse?

A) remind the patient of her injury and try to comfort her
B) call the healthcare provider and get an order for radiologic evaluation
C) prepare the patient for surgery, as her condition is worsening
D) explain to the patient that this could be a common, temporary problem

Question 9

The nurse understands that when the spinal cord is injured, ischemia and edema result. How should the nurse explain to the patient the reason that the extent of injury cannot be determined for several days to a week?

A) "Tissue repair does not begin for 72 hours."
B) "The edema extends the level of injury two cord segments above and below the affected level."
C) "Neurons need time to regenerate, so stating the extent of injury early is not predictive of how the patient progresses."
D) "Necrosis of gray and white matter does not occur until days after the injury."

Question 10

The nurse is preparing an educational session about spinal cord injury (SCI) prevention for a community group. What patient example should the nurse use to explain the risk factors for this type of injury?

A) 18-year-old male with a prior arrest for driving while intoxicated (DWI)
B) 28-year-old female with a history of substance abuse
C) 50-year-old female with osteoporosis
D) 35-year-old male who coaches a soccer team

Question 11

The nurse is educating a patient and the family about different types of stabilization devices. Which statement indicates that the patient understands the benefit of using a halo fixation device instead of Gardner-Wells tongs?

A) "I will have less pain if I use the halo device."
B) "The halo device will allow me to get out of bed."
C) "I am less likely to get an infection with the halo device."
D) "The halo device does not have to stay in place as long."

Question 12

A patient with a spinal cord injury is recovering from spinal shock. The nurse realizes that the patient should not develop a full bladder because what emergency condition can occur if it is not corrected quickly?

A) autonomic dysreflexia
B) autonomic crisis
C) autonomic shutdown
D) autonomic failure

Question 13

A patient is placed in ventilator support with the diagnosis of botulism and failure to thrive. Which nursing actions would be most appropriate for this patient?

A) maintaining intravenous fluids at KVO (keep vein open)
B) assessing bowel sounds once a shift
C) referring the patient for a physical therapy consult
D) monitoring total parenteral nutrition infusion
E) assessing urinary output every hour

Question 14

The healthcare provider prescribes 2.5 mg IV of morphine sulfate to be administered to a patient with a ruptured intervertebral disk whose pain has not been controlled with NSAIDs and muscle relaxants. The nurse has a 1 milliliter (mL) syringe containing 10 mg of morphine sulfate. How many milliliters of morphine sulfate does the nurse need to withdraw from the syringe?
_____ mL
Standard Text: Calculate the exact dosage.

Question 15

A lumbar puncture (LP) is performed on a patient to rule out a spinal cord tumor. The cerebrospinal fluid (CSF) is xanthochromic, has increased protein and no cells, and clots immediately. What syndrome should the nurse suspect this patient is experiencing?

A) Glasgow syndrome
B) Froin syndrome
C) cord tumor syndrome
D) reflex syndrome

Question 16

A patient with a spinal cord injury at the T1 level complains of a severe headache and an "anxious feeling." Which is the most appropriate initial reaction by the nurse?

A) to try to calm the patient and make the environment soothing
B) to assess for a full bladder
C) to notify the healthcare provider
D) to prepare the patient for diagnostic radiography

Question 17

A patient recovering from a spinal cord injury (SCI) is experiencing gastric distress. Which medication should the nurse expect to be prescribed for this patient?

A) omeprazole (Prilosec)
B) dopamine (Intropin)
C) baclofen (Lioresal)
D) dantrolene (Dantrium)

Question 18

A victim of a motor vehicle crash has an acute cervical spinal cord injury. Which problem should the nurse identify as the priority for this patient?

A) fluid maintenance
B) changes in mobility
C) problems with the airway
D) altered blood flow

Question 19

A school nurse is called after a student falls down a flight of stairs. The student is breathing but unconscious. After calling the ambulance, what should the nurse do?

A) assess the neck for movement
B) place the patient on the side to prevent aspiration
C) immobilize the neck, securing the head
D) try to rouse the patient by gently shaking the shoulders

Question 20

The nurse is planning care for a patient recovering from spinal fusion surgery. What should the nurse identify as goals of care for this patient?

A) maximizing comfort
B) controlling pain
C) promoting body alignment
D) preventing injury
E) promoting nutritional intake

Question 21

A nurse working with postpoliomyelitis patients knows that most of the patients:

A) had the initial infection in the 1940s and 1950s.
B) have muscle involvement only in muscle groups that were affected initially.
C) have few symptoms other than mild muscle and joint weakness and pain.
D) had a recurrence due to receiving an oral polio vaccine booster.

Question 22

A patient with a chronic sinus infection is diagnosed with a brain abscess. What medications should the nurse expect to provide to this patient?

A) morphine sulfate
B) digitalis (Digoxin)
C) phenytoin (Dilantin)
D) acetaminophen (Tylenol)
E) broad-spectrum antibiotic

Question 23

The nurse suspects that a patient with a spinal cord injury is experiencing autonomic dysreflexia. Which findings will help the nurse determine the cause for this condition?

A) hypertension
B) kinked catheter tubing
C) respiratory wheezes and stridor
D) diarrhea
E) fecal impaction

Question 24

A patient is diagnosed with a lumbosacral spinal cord tumor. Which medications should the nurse expect to be prescribed for this patient?

A) morphine
B) furosemide (Lasix)
C) warfarin (Coumadin)
D) amoxicillin (Amoxil)
E) dexamethasone (Decadron)

Question 25

A patient with protruding lumbar disks is scheduled for a laminectomy. What should the nurse instruct the patient about this surgery?

A) The surgery will relieve pressure on the nerves.
B) A hollow titanium cylinder will be placed over the spine.
C) The spaces where the spinal nerves exit the canal will be enlarged.
D) The bony arch on the surface of the vertebra will be removed.
E) Wedge-shaped pieces of bone will be inserted between the vertebrae.

Question 26

The nurse is preparing an educational program on bacterial meningitis for a group of community members. Which groups should the nurse identify as being at greatest risk for this infection?

A) older adults
B) pregnant women
C) military recruits
D) college students
E) low-income individuals

Question 27

A patient recovering from a laminectomy reports a pain level of 10 on a scale of 0 to 10. The patient says something must be wrong because the pain is worse than it was before the surgery. How should the nurse respond?

A) "The discomfort is not pain but rather muscle spasms."
B) "I'm sure you will need more surgery, so I will be back to get you."
C) "The surgery caused edema of the nerve roots, which increases the amount of pain."
D) "Pain is an indication that something is wrong. I will contact the surgeon."

Question 28

An unconscious patient receiving emergency care following an automobile crash accident has a possible spinal cord injury. What guidelines for emergency care should be followed?

A) Immobilize the patient's neck using rolled towels or a cervical collar.
B) Place the patient in a supine position
C) Place the patient on a ventilator.
D) Elevate the head of the bed.
E) Secure the patient's head with a belt or tape secured to the stretcher.

Question 29

An industrial nurse is conducting a class on ways to prevent back pain. What should the nurse include when teaching about lifting heavy objects?

A) Spread the feet apart to broaden the base of support.
B) Use the legs to push when lifting.
C) Stand as closely as possible to the object to be moved.
D) Roll or push the object instead of lifting.
E) Bend at the waist over the center of gravity.

Question 30

A mother takes her young child to an urgent care clinic requesting "the shot you get to prevent rabies," as her son was bitten by a wild raccoon. What is the appropriate response by the nurse?

A) "Care of a bite victim includes a series of immunizations on the day of exposure and on days 3, 7, 14, and 28 after exposure."
B) "The animal needs to be quarantined first, to determine if it has rabies, before immunizations are started."
C) "Your child will need penicillin because the wound can easily become infected."
D) "Wait a week to see if your child develops any symptoms. Then the immunization will be given."

Question 31

The nurse is giving a lecture at a health fair when a member of the audience asks: "Why do people say you shouldn't eat foods that come from cans that are bulging, as if the seal has been broken?" How should the nurse respond?

A) "It may be a sign that botulism toxins are present, because the food has been improperly processed and sealed."
B) "Arboviruses may be found in canned foods that appear damaged."
C) "The bacteria Clostridium tetani grows in poorly processed foods or damaged cans."
D) "Open the can, and if no bubbles, bad odor, or change in color is present, you can eat the contents."

Question 32

The nurse is instructing a patient with a ruptured vertebral disk on self-care measures. What should the nurse include in this teaching?

A) Bend from the waist.
B) Wear low-heeled shoes.
C) Avoid twisting the back.
D) Sleep on a firm mattress.
E) Use a pillow under the knees when lying down.

Question 33

A patient is admitted to the hospital with a suspected case of botulism. The nurse recognizes that which situation likely caused this infection?

A) The patient ate food contaminated with the toxin.
B) The patient came in contact with someone who had botulism.
C) The patient was injected with the poison.
D) The patient had a dirty wound that became infected with the toxin.

Question 34

A college student is admitted for treatment of viral meningitis. What should the nurse expect to assess in this patient?

A) lethargy
B) confusion
C) photophobia
D) neck stiffness
E) positive Kernig sign

Question 35

A patient being treated for cat scratches is concerned about tetanus. Which method should the nurse describe as a way to completely prevent the development of tetanus?

A) active immunization
B) debriding the bite wound
C) passive immunization
D) administering antibiotics immediately after a bite

Question 36

The nurse instructs a patient with herniated thoracic and lumbar disks about spinal fusion surgery. Which patient statements indicate that teaching has been effective?

A) "Bone chips might be taken from my iliac crest bone."
B) "Holes will be drilled into my skull so that a brace can be placed."
C) "Bone chips will be wedged between the vertebrae to stabilize them."
D) "I will need to stay on bed rest because traction will be applied to my spine."
E) "A hollow titanium tube might be placed in my spine to replace a removed disk."

Question 37

A patient is admitted with injuries sustained in a fall. During the nurse's first assessment upon admission, the findings are: blood pressure 90/60 (as compared to 136/66 in the emergency department), flaccid paralysis on the right, absent bowel sounds, zero urine output, and palpation of a distended bladder. The nurse realizes that these findings are consistent with which condition?

A) paralysis
B) spinal shock
C) high cervical injury
D) temporary hypovolemia

Question 38

Postpoliomyelitis syndrome is seen in about 50% of patients who had the poliomyelitis virus many years ago. While the pathophysiology is not understood, what should the nurse anticipate?

A) caring for patients with progressive muscle weakness, fatigue, and pain; muscle atrophy and scoliosis
B) a new outbreak of polio and the need for a new immunization program
C) caring for patients with respiratory complications who must be quarantined
D) working with patients who have polio again

Question 39

The nurse is concerned that a patient with a spinal cord tumor is developing syringomyelia. What did the nurse assess to make this clinical decision?

A) pain
B) spasticity
C) numbness
D) leg weakness
E) cool extremities

Question 40

A patient with a spinal cord injury (SCI) has complete paralysis of both upper and lower extremities. Which term should the nurse use when documenting this patient's status?

A) hemiplegia
B) paresthesia
C) paraplegia
D) quadriplegia