Question 1

The nurse assessing a patient with newly diagnosed trigeminal neuralgia will ask the patient about

Accepted Answer

The major clinical manifestation of trigeminal neuralgia is severe facial pain triggered by cutaneous stimulation of the nerve. Ptosis,loss of taste,and facial weakness are not characteristics of trigeminal neuralgia.

Question 2

The nurse is admitting a patient who has a neck fracture at the C6 level to the intensive care unit. Which assessment findings indicate neurogenic shock?

Accepted Answer

Neurogenic shock is characterized by hypotension,bradycardia,and vasodilation leading to warm skin temperature. Spasticity and hyperactive reflexes do not occur at this stage of spinal cord injury. Lack of movement and sensation indicate spinal cord injury but not neurogenic shock.

Question 3

A patient with Bell's palsy refuses to eat while others are present because of embarrassment about drooling. The best response by the nurse is to

Accepted Answer

The patient's desire for privacy should be respected to encourage adequate nutrition and reduce patient embarrassment. Liquid supplements may help maintain nutrition but will reduce the patient's enjoyment of the taste of food. It would be inappropriate for the nurse to discuss the patient's embarrassment with visitors unless the patient wishes to share this information. Chewing on the unaffected side of the mouth will enhance nutrition and enjoyment of food but will not decrease the drooling.

Question 4

A 38-yr-old patient who has had a spinal cord injury returned home following a stay in a rehabilitation facility. The home care nurse notes the spouse is performing many of the activities that the patient had been managing unassisted during rehabilitation. The appropriate nursing action at this phase of rehabilitation is to

Accepted Answer

The best action by the nurse will be to involve all parties in developing an optimal plan of care. Because family members who will be assisting with the patient's ongoing care need to believe their input is important,telling the spouse that the patient can perform activities independently is not the best choice. Reminding the patient about the importance of independence may not change the behaviors of the spouse. Supporting the activities of the spouse will lead to ongoing dependency by the patient.

Question 5

Which action will the nurse include in the plan of care for a patient who is experiencing pain from trigeminal neuralgia?

Accepted Answer

The patient with an acute episode of trigeminal neuralgia may be unwilling to eat or drink,so assessment of nutritional and hydration status is important. Because stimulation by touch is the precipitating factor for pain,relaxation of the facial muscles will not improve symptoms. Application of ice is likely to precipitate pain. The patient will not want to engage in conversation,which may precipitate attacks.

Question 6

To prevent autonomic hyperreflexia,which nursing action will the home health nurse include in the plan of care for a patient who has paraplegia at the T4 level ?

Accepted Answer

Fecal impaction is a common stimulus for autonomic hyperreflexia. Dietary protein,coughing,and discussing sexuality and fertility should be included in the plan of care but will not reduce the risk for autonomic hyperreflexia.

Question 7

When evaluating outcomes of a glycerol rhizotomy for a patient with trigeminal neuralgia,the nurse will

Accepted Answer

Because withdrawal from social activities is a common manifestation of trigeminal neuralgia,asking about social activities will help in evaluating if the patient's symptoms have improved. Glycerol rhizotomy does not damage the corneal reflex or motor functions of the trigeminal nerve,so there is no need to use an eye shield,do facial exercises,or take precautions with chewing.

Question 8

A patient is hospitalized with new onset of Guillain-Barré syndrome. The most essential assessment for the nurse to complete is

Accepted Answer

The most serious complication of Guillain-Barré syndrome is respiratory failure,and the nurse should monitor respiratory function continuously. The other assessments will also be included in nursing care,but they are not as important as respiratory assessment.

Question 9

A construction worker arrives at an urgent care center with a deep puncture wound from a rusty nail. The patient reports having had a tetanus booster 6 years ago. The nurse will anticipate

Accepted Answer

If the patient has not been immunized in the past 5 years,administration of the Td booster is indicated because the wound is deep. Immune globulin administration is given by the IM route if the patient has no previous immunization. Administration of a series of immunization is not indicated. TIG is not indicated for this patient,and a test dose is not needed for immune globulin.

Question 10

The nurse will explain to the patient who has a T2 spinal cord transection injury that

Accepted Answer

The patient with a T2 injury can expect to retain full motor and sensory function of the arms. Use of only the shoulders is associated with cervical spine injury. Loss of respiratory function occurs with cervical spine injuries. Bradycardia is associated with injuries above the T6 level.

Question 11

Which patient assessment will help the nurse identify potential complications of trigeminal neuralgia?

Accepted Answer

Oral hygiene is frequently neglected because of fear of triggering facial pain and may lead to gum disease,dental caries,or an abscess. Having the patient clench the facial muscles will not be useful because the sensory branches (rather than motor branches)of the nerve are affected by trigeminal neuralgia. Light touch and palpation may be triggers for pain and should be avoided.

Question 12

A patient with paraplegia resulting from a T9 spinal cord injury has a neurogenic reflexic bladder. Which action will the nurse include in the plan of care?

Accepted Answer

Because the patient's bladder is spastic and will empty in response to overstretching of the bladder wall,the most appropriate method is to avoid incontinence by emptying the bladder at regular intervals through intermittent catheterization. Assisting the patient to the toilet will not be helpful because the bladder will not empty. The Credé method is more appropriate for a bladder that is flaccid,such as occurs with areflexic neurogenic bladder. Catheterization after voiding will not resolve the patient's incontinence.

Question 13

A 20-yr-old patient who sustained a T2 spinal cord injury 10 days ago tells the nurse,"I want to be transferred to a hospital where the nurses know what they are doing." Which action by the nurse is appropriate?

Accepted Answer

The patient is demonstrating behaviors consistent with the anger phase of the grief process,and the nurse should allow expression of anger and seek the patient's input into care. Expression of anger is appropriate at this stage,and should be accepted by the nurse. Reassurance about the competency of the staff will not be helpful in responding to the patient's concerns. Ignoring the patient's comments will increase the patient's anger and sense of helplessness.

Question 14

A patient is admitted with possible botulism poisoning after eating home-canned green beans. Which intervention ordered by the health care provider will the nurse question?

Accepted Answer

The patient should be maintained on NPO status because neuromuscular weakness increases risk for aspiration. Side-lying position is not contraindicated. Assessment of neurologic and respiratory status is appropriate.

Question 15

A patient hospitalized with a new diagnosis of Guillain-Barré syndrome has numbness and weakness of both feet. The nurse will anticipate teaching the patient about

Accepted Answer

Because Guillain-Barré syndrome is in the earliest stages (as evidenced by the symptoms),use of high-dose immunoglobulin is appropriate to reduce the extent and length of symptoms. Mechanical ventilation and tube feedings may be used later in the progression of the syndrome but are not needed now. Corticosteroid use is not helpful in reducing the duration or symptoms of the syndrome.

Question 16

Which assessment data for a patient who has Guillain-Barré syndrome will require the nurse's most immediate action?

Accepted Answer

Drooling indicates decreased ability to swallow,which places the patient at risk for aspiration and requires rapid nursing and collaborative actions such as suctioning and possible endotracheal intubation. The foot pain should be treated with appropriate analgesics,the BP requires ongoing monitoring,and the skin integrity requires intervention,but these actions are not as urgently needed as maintenance of respiratory function.

Question 17

The nurse identifies a patient with type 1 diabetes and a history of herpes simplex infection as being at risk for Bell's palsy. Which information should the nurse include in teaching the patient?

Accepted Answer

Pain or herpes lesions near the ear may indicate the onset of Bell's palsy,and rapid corticosteroid treatment may reduce the duration of Bell's palsy symptoms. Antiviral therapy for herpes simplex does not reduce the risk for Bell's palsy. Corticosteroid therapy will be most effective in reducing symptoms if started before paralysis is complete but will still be somewhat effective when started later. Facial exercises do not prevent Bell's palsy.

Question 18

Which nursing action has the highest priority for a patient who was admitted 16 hours earlier with a C5 spinal cord injury?

Accepted Answer

Edema around the area of injury may lead to damage above the C4 level,so the highest priority is assessment of the patient's respiratory function. The other actions also are appropriate for preventing deterioration or complications but are not as important as assessment of respiratory effort.

Question 19

When the nurse is developing a rehabilitation plan for a 30-yr-old patient with a C6 spinal cord injury,an appropriate goal is that the patient will be able to

Accepted Answer

The patient with a C6 injury will be able to use the hands to push a wheelchair on flat,smooth surfaces. Because flexion of the thumb and fingers is minimal,the patient will not be able to grasp a wheelchair during transfer,drive a car with powered hand controls,or turn independently in bed.

Question 20

A patient has an incomplete left spinal cord lesion at the level of T7,resulting in Brown-Séquard syndrome. Which nursing action should be included in the plan of care?

Accepted Answer

The patient with Brown-Séquard syndrome has loss of motor function on the ipsilateral side and will require the nurse to move the left leg. Pain sensation will be lost in the patient's right leg. Arm weakness will not be a problem for a patient with a T7 injury. The patient will retain position sense for the right leg.

Quiz 60: Spinal Cord and Peripheral Nerve Problems