Deck 36: Dysfunction of the Spinal Cord and Peripheral Nervous System: Nursing Management

Question 1

A client diagnosed with Bell's palsy asks the nurse why eye drops have been prescribed. Which of the following should the nurse respond to this client?

A) "Eyes tend to dry out because the eyelids do not close."
B) "Eyes become irritated because the eye does not make tears."
C) "Eyes trap dust because the eyelid does not open and the eye needs to be flushed."
D) "The eye drops should not be prescribed and the physician should be notified."

Answer 1

"Eyes tend to dry out because the eyelids do not close."

Question 2

The nurse is preparing a community education program on the prevention of spinal cord injuries. Which of the following individuals would most likely benefit from this education?

A) Adolescent female who plays golf
B) Adolescent male who rides horses
C) Thirty-year-old female housewife
D) Fifty-year-old male who is a computer technician

Answer 2

Adolescent male who rides horses

Question 3

The nurse, planning care for a client diagnosed with a spinal cord injury, would include interventions to address autonomic dysreflexia because the client's spinal cord injury is at which of the following levels?

A) L5
B) T12
C) S1
D) T4

Answer 3

T4

Question 4

A client experienced a spinal cord injury during a football game. The paramedics applied a neck brace prior to moving the client onto a hard board for transportation. The nurse realizes that the neck brace was provided because the area of the spinal cord most vulnerable to injury is:

A) coccygeal.
B) lumbar.
C) thoracic.
D) cervical.

Question 5

The nurse is preparing to administer high-dose methylprednisolone to a client diagnosed with a spinal cord injury. The nurse realizes that for this medication to be most effective treatment should begin:

A) within 8 hours of injury.
B) between 8 and 12 hours of injury.
C) between 12 and 24 hours of injury.
D) 48 hours after the injury.

Question 6

A client is diagnosed with a peripheral nerve injury. Which of the following will the nurse most likely assess in this client? (Select all that apply.)

A) Paresthesias
B) Paralysis
C) Hypotension
D) Cardiac dysrhythmias
E) Paresis
F) Pain

Question 7

The nurse realizes that most spinal cord injuries are caused by: (Select all that apply.)

A) falls.
B) motor vehicle crashes.
C) sports injuries.
D) gunshot wounds.
E) walking.
F) gardening.

Question 8

A client is diagnosed with Bell's palsy. Which of the following will the nurse most likely assess in this client?

A) Facial weakness
B) Dry eye
C) Drooling
D) Impaired speech
E) Dizziness
F) Shortness of breath

Question 9

The nurse is caring for a client receiving radiation for a spinal cord tumor. The nurse realizes that interventions need to be planned to address which of the following potential complications of this treatment? (Select all that apply.)

A) Increasing neurological impairment
B) Paralysis
C) Decubitus ulcers
D) Peripheral vascular disease
E) Loss of bowel and bladder function
F) Osteoporosis

Question 10

A client diagnosed with a spinal cord tumor is being prepared for treatment. The nurse realizes that treatment will include irradiation along with which of the following?

A) Tylenol
B) Vicodin
C) Reglan
D) Dexamethasone

Question 11

A client diagnosed with a spinal cord injury has been experiencing spinal shock. Which of the following assessment findings would indicate that this shock is resolving?

A) Blood pressure 80/55 mmHg
B) Heart rate 48 beats per minute
C) Reflexive emptying of the bladder
D) Body temperature 97°F

Question 12

A client is being evaluated for the presence of carpal tunnel syndrome. Which of the following diagnostic tests will be used to aid in the diagnosis of this disorder? (Select all that apply.)

A) Electromyography
B) Electroencephalogram
C) Electrocardiogram
D) Allen's test
E) Tinel's sign
F) Phalen's sign

Question 13

A client receiving care for a spinal cord injury complains of a pounding headache, blurred vision, and has a blood pressure of 200/100 mmHg. What is the first action the nurse should take?

A) Administer pain medication.
B) Position the client on the left side.
C) Turn off the lights and decrease the noise in the room.
D) Check the bladder for distension.

Question 14

The nurse is caring for a client with a spinal cord injury located at T

A) Use mechanical ventilation.
B) Assess blood glucose level for onset of diabetes.
C) Assist with removal of pulmonary secretions.
D) Provide assistive devices for ambulation.
E) Which of the following should be included in this client's plan of care?

Question 15

A client is recovering from a spinal cord injury at level T

A) Medical
12) Once spinal shock has resolved and the client's status has stabilized, the client will need which of the following types of care going forward?
B) Nursing
C) Physical therapy
D) Spiritual

Question 16

A client is diagnosed with Guillain-Barré syndrome. The nurse would assess that signs and symptoms of the disorder would appear in which of the following order?

A) In the hands and arms, progressing to the shoulders and head
B) At the top of the spine, progressing to the brain
C) In the legs, progressing up the body
D) In the face, spreading over the entire facial muscles

Question 17

The nurse is determining diagnoses appropriate for a client newly diagnosed with Guillian-Barré syndrome. Which of the following nursing diagnoses would be appropriate for this client?

A) Risk for injury
B) Ineffective breathing pattern
C) Risk for infection
D) Pain

Question 18

Which of the following should the nurse instruct a client diagnosed with trigeminal neuralgia to help control symptoms?

A) Perform active range-of-motion exercises to all extremities.
B) Avoid extreme temperature variances in food and drink.
C) Stay in bed with little movement.
D) Drink eight glasses of water a day.