Question 1

After teaching a client with a spinal cord tumor,the nurse assesses the client's understanding.Which statements by the client indicate a correct understanding of the teaching? (Select all that apply.)

Accepted Answer

Although surgery may relieve symptoms by reducing pressure on the spine and debulking the tumor,some motor and sensory deficits may remain.Spinal tumors usually cause disability but are not usually fatal.Radiation therapy is often used to shrink spinal tumors but can cause progressive spinal cord degeneration and neurologic deficits.The client should be turned every 2 hours to prevent skin breakdown and arrangements should be made at home so that the client can complete activities of daily living without needing to go up and down stairs.

Question 2

A nurse assesses a client who recently experienced a traumatic spinal cord injury.Which assessment data should the nurse obtain to assess the client's coping strategies? (Select all that apply.)

Accepted Answer

Information about the client's preinjury psychosocial status,usual methods of coping with illness,difficult situations,and disappointments should be obtained.Determine the client's level of independence or dependence and his or her comfort level in discussing feelings and emotions with family members or close friends.Clients who are emotionally secure and have a positive self-image,a supportive family,and financial and job security often adapt to their injury.Information about the client's spiritual and religious beliefs or cultural background also assists the nurse in developing the plan of care.The other options do not supply as much information about coping.

Question 3

A nurse cares for a client with amyotrophic lateral sclerosis (ALS).The client states,"I do not want to be placed on a mechanical ventilator." How should the nurse respond?

Accepted Answer

ALS is an adult-onset upper and lower motor neuron disease characterized by progressive weakness,muscle wasting,and spasticity,eventually leading to paralysis.Once muscles of breathing are involved,the client must indicate in the advance directive what is to be done when breathing is no longer possible without intervention.The other statements do not address the client's needs.

Question 4

A nurse plans care for a client with a halo fixator.Which interventions should the nurse include in this client's plan of care? (Select all that apply.)

Accepted Answer

A special halo wrench should be taped to the client's vest in case of a cardiopulmonary emergency.The nurse should assess the pin sites for signs of infection or loose pins and for complications from the halo.The nurse should also increase fluids and fiber to decrease bowel straining and assess the client's chest and back for skin breakdown from the halo vest.

Question 5

A nurse assesses a client who experienced a spinal cord injury at the T5 level 12 hours ago.Which manifestations should the nurse correlate with neurogenic shock? (Select all that apply.)

Accepted Answer

Neurogenic shock with acute spinal cord injury manifests with decreased oxygen saturation,symptomatic bradycardia,decreased level of consciousness,decreased urine output,and hypotension.

Question 6

A nurse assesses the health history of a client who is prescribed ziconotide (Prialt)for chronic back pain.Which assessment question should the nurse ask?

Accepted Answer

Clients who have a mental health or behavioral health problem should not take ziconotide.The other questions do not identify a contraindication for this medication.

Question 7

A nurse assesses a client who is recovering from a lumbar laminectomy.Which complications should alert the nurse to urgently communicate with the health care provider? (Select all that apply.)

Accepted Answer

Bulging at the incision site or clear fluid on the dressing after a laminectomy strongly suggests a cerebrospinal fluid leak,which constitutes an emergency.Loss of cerebral spinal fluid may cause a sudden and severe headache,which is also an emergency situation.Pain,redness,and itching at the site are normal.

Question 8

After teaching a male client with a spinal cord injury at the T4 level,the nurse assesses the client's understanding.Which client statements indicate a correct understanding of the teaching related to sexual effects of this injury? (Select all that apply.)

Accepted Answer

Men with injuries above T6 often are able to have erections by stimulating reflex activity.For example,stroking the penis will cause an erection.Ejaculation is less predictable and may be mixed with urine.However,urine is sterile,so the client's partner will not get an infection.

Question 9

A nurse cares for a client with a lower motor neuron injury who is experiencing a flaccid bowel elimination pattern.Which actions should the nurse take to assist in relieving this client's constipation? (Select all that apply.)

Accepted Answer

For the client with a lower motor neuron injury,the resulting flaccid bowel may require a bowel program for the client that includes stool softeners,increased fluid intake,a high-fiber diet,and a consistent elimination time.If the client becomes impacted,the nurse would need to perform manual disimpaction.Pouring warm water over the perineum,administering daily enemas,and massaging the abdomen would not assist this client.

Question 10

A nurse assesses a client with paraplegia from a spinal cord injury and notes reddened areas over the client's hips and sacrum.Which actions should the nurse take? (Select all that apply.)

Accepted Answer

Appropriate interventions to relieve pressure on these areas include frequent re-positioning and a low-air-loss mattress.Reddened areas should not be rubbed because this action could cause more extensive damage to the already fragile capillary system.Barrier cream will not protect the skin from pressure wounds.ROM exercises are used to prevent contractures.Sitting the client in a chair once a day will decrease the client's risk of respiratory complications but will not decrease pressure on the client's hips and sacrum.

Quiz 43: Care of Patients with Problems of the Central Nervous System: The Spinal Cord