Deck 63: Nursing Management: Peripheral Nerve and Spinal Cord Problems

Question 1

The nurse is aware that which one of the following is the most common cause of premature death in a patient with tetraplegia?

A) Diabetes
B) Acute renal failure
C) Pneumonia
D) Hypertension

Answer 1

Pneumonia

Question 2

A patient with a paraplegia resulting from a T10 spinal cord injury has a neurogenic reflex bladder.The nurse consults with the physician regarding bladder management,recommending that which of the following initial treatments should be included?

A) Intermittent catheterization every 4 hours
B) Limiting fluid intake to 1000 mL/day
C) Clamping a Foley catheter and draining it every 2 hours
D) Catheterization for residual urine after each voiding

Answer 2

Intermittent catheterization every 4 hours

Question 3

A patient with a spinal cord transection at T1 is in spinal shock.While monitoring the patient,the nurse recognizes that alterations in sympathetic nervous system function may cause which of the following reactions?

A) Tachycardia
B) Bladder hyperirritability
C) Fluctuating body temperature
D) Hypermotility of the gastrointestinal system

Answer 3

Fluctuating body temperature

Question 4

A patient with Guillain-Barré syndrome asks the nurse what has caused the disease.In responding to the patient,what should the nurse explain about Guillain-Barré syndrome?

A) Results from an acute infection and inflammation of the peripheral nerves
B) Is due to an immune reaction that attacks the covering of the peripheral nerves
C) Is caused by destruction of the peripheral nerves after exposure to a viral infection
D) Results from degeneration of the peripheral nerve caused by viral attacks

Question 5

The physician orders administration of IV methylprednisolone for the first 24 hours to a patient who experienced a spinal cord injury 3 hours ago.What will the nurse assess when evaluating the effectiveness of this drug?

A) Blood pressure and heart rate
B) Respiratory effort and O₂ saturation
C) Motor and sensory function of the legs
D) Bowel sounds and abdominal distension

Question 6

When planning care for a patient during an acute episode of trigeminal neuralgia,what is an appropriate intervention to include?

A) Evaluation of hydration and nutrition status
B) Exercise of the muscles of the face and jaw
C) Application of ice packs to the affected area
D) Regular exercise regimen

Question 7

When caring for a patient who had a C8 spinal cord injury 10 days ago and has a weak cough effort,bibasilar crackles,and decreased breath sounds,the initial nursing intervention should be to do which of the following?

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

Question 8

A patient with Bell's palsy refuses to eat while others are present.What is the best response to the patient's behaviour?

A) Respect her desire for privacy,and leave her alone while she eats.
B) Provide a liquid diet high in protein and calories,which she can easily swallow.
C) Assure the patient that it does not bother others to observe her while she eats.
D) Teach the patient to chew her food on the unaffected side of the mouth for better control.

Question 9

When assessing a patient with newly diagnosed trigeminal neuralgia,the nurse will ask the patient about which of the following?

A) Triggers that lead to facial pain
B) Visual problems caused by ptosis
C) Poor appetite caused by a loss of taste
D) Decreased sensation on the affected side

Question 10

A patient arrives at an urgent care centre after stepping on a nail that was embedded in some old lumber in a field.The patient reports having had a tetanus booster 7 years ago.What will the nurse anticipate for care?

A) Intravenous (IV)infusion of tetanus immune globulin
B) Initiation of the tetanus-diphtheria (Td)immunization series
C) Intradermal injection of an immune globulin test dose
D) Administration of the Td toxoid booster

Question 11

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

Question 12

A patient admitted to the emergency department is diagnosed with botulism poisoning,and botulinum antitoxin is to be administered.Before administration of the antitoxin,what should the nurse do?

A) Obtain baseline vital signs.
B) Administer an intradermal test dose.
C) Ask the patient about a history of allergies.
D) Document the presence of neurological symptoms.

Question 13

As a result of a gunshot wound,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 14

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

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

Question 15

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

A) Monitoring the vital signs every 2 hours
B) Determining the patient's level of consciousness every 2 hours
C) Performing constant evaluation of respiratory function
D) Evaluating sensory and motor function of the extremities

Question 16

A patient with a cervical neck fracture at the C5 level is admitted to the critical care unit following initial treatment in the emergency department.During initial assessment of the patient,the nurse recognizes the presence of spinal shock on finding which of the following data?

A) Hypotension,bradycardia,and warm extremities
B) Involuntary,spastic movements of the arms and legs
C) Flaccid paralysis and lack of sensation below the level of the injury
D) Loss of voluntary motor control but the presence of reflex activity below the level of the injury

Question 17

During assessment of the patient with a recurrence of symptoms of trigeminal neuralgia,what should the nurse do?

A) Examine the oral cavity for the state of hygiene.
B) Observe the extent of facial weakness and eye closure.
C) Identify trigger zones by lightly tickling the affected side of the face.
D) Gently palpate the affected side of the face for warmth and swelling.

Question 18

During the initial phase of care for a patient with spinal cord trauma at C5,why must the nurse give high priority to maintaining respiratory function?

A) At the C5 level,diaphragmatic and intercostal muscle function is lost.
B) Extension of edema above the site of the injury may affect phrenic nerve function.
C) Immobilization of the patient's spine promotes pooling of respiratory secretions.
D) Without abdominal muscle control,the patient cannot adequately cough to clear the lungs.

Question 19

A patient with a long history of trigeminal neuralgia recently had a glycerol rhizotomy for control of symptoms.During a follow-up visit after the rhizotomy,what finding indicates to the nurse that the patient has made a successful adjustment to the surgical intervention?

A) The patient uses an eye shield to protect the cornea from injury.
B) The patient develops and implements a daily routine of facial exercises.
C) The patient is careful to chew foods on the unaffected side of the mouth.
D) The patient returns to previous interpersonal and social relationships with family and friends.

Question 20

A 45-year-old woman is hospitalized with Guillain-Barré syndrome.What treatment will the nurse explain will most likely be included during the first 2 to 3 weeks of her illness?

A) Hemodialysis
B) Mechanical ventilation
C) Administration of immune globulin (Sandoglobulin)
D) Administration of methylprednisolone (Solu-Medrol)

Question 21

When assessing a patient's grade of impairment,the nurse documents that motor function is preserved below the neurological level and more than half of the key muscle functions below the level have a muscle grade of 2.According to the American Spinal Injury Association Impairment Scale,what grade would the nurse document?

A) A
B) B
C) C
D) D

Question 22

A 26-year-old patient with a C8 spinal cord injury tells the nurse that sexual activity has always been very important to him and his wife,and he worries she may leave him if he cannot function sexually.What is the most appropriate response to the patient's comment?

A) Advise the patient to talk to his wife about his concerns.
B) Tell the patient that alternative methods of obtaining sexual satisfaction could be used.
C) Inform the patient that most patients with upper motor neuron injuries have reflex erections.
D) Suggest that the patient and his wife work with a nurse specially trained in sexual counselling.

Question 23

A patient with a T2 spinal cord injury is beginning intensive rehabilitation.One morning as the nurse prepares to assist her to transfer to the wheelchair,the patient tells the nurse that she does not feel like getting up,that she has a throbbing headache,and that she is slightly nauseated.What is it most important that the nurse do?

A) Notify the physician.
B) Check the patient's blood pressure.
C) Tell her she will feel better if she sits upright in her wheelchair.
D) Do a digital rectal examination for the presence of an impaction.

Question 24

Which of the following would the nurse expect from a patient with a spinal cord injury at the level of C7?

A) The patient is able to stand with long leg braces.
B) The patient is independent in all self-care activities.
C) The patient is independent with transferring from a wheelchair to bed.
D) The patient may require assistance with bowel functioning.

Question 25

Spinal cord injuries occur most frequently in which age group?

A) 1 to 8 years
B) 10 to 15 years
C) 15 to 25 years
D) 35 to 50 years

Question 26

The nurse discusses long-range goals with a patient with a C6 spinal cord injury.What is an appropriate patient outcome for the patient?

A) Transfers independently to a wheelchair
B) Drives a car with powered hand controls
C) Feeds himself with powered hand splints
D) Pushes a wheelchair on flat,smooth surfaces

Question 27

A patient is exhibiting signs of autonomic dysreflexia.Which of the following would the nurse do first?

A) Raise the patient to a sitting position.
B) Check bladder for distension.
C) Assess for tight clothing.
D) Call the health care provider.

Question 28

A young married woman has returned home following extensive rehabilitation for a C8 spinal cord injury.The home health care nurse visits and notices that the patient's mother and husband are performing many of the activities of daily living that the patient was managing during rehabilitation.What is the most appropriate nursing action at this time?

A) Encourage the patient to perform her own care as she has been taught.
B) Tell the mother and the husband to stop performing care that the patient can do herself.
C) Recognize that it is important for the patient's family to be involved in her care and support their activities.
D) Include the husband and the mother in developing a plan of care to increase the patient's independence.

Question 29

A patient who sustained a T1 spinal cord injury a week ago refuses to discuss the injury and becomes verbally abusive to the nurses and other staff.The patient demands to be transferred to another hospital,where "they know what they are doing." What is the best response to the patient's behaviour?

A) Ask for the patient's input into the plan for care.
B) Clarify that abusive behaviour will not be tolerated.
C) Reassure the patient that the anger will pass and rehabilitation will then progress.
D) Ignore the patient's anger and continue to perform needed assessments and care.