Question 1

A nurse who works on the neurology unit just received change-of-shift report.Which patient will the nurse assess first?

Accepted Answer

The patient's diagnosis and difficulty swallowing indicate that the nurse should rapidly assess for respiratory distress.The information about the other patients is consistent with their diagnoses and does not indicate any immediate need for assessment or intervention.

Question 2

Following a cauda equina spinal cord injury,which action will the nurse include in the plan of care?

Accepted Answer

Patients with cauda equina syndrome have areflexic bladder,and intermittent catheterization will be used for emptying the bladder.Because the bladder is flaccid,antispasmodic medications will not be used.The legs are flaccid with cauda equina syndrome and the patient will be unable to ambulate.The head and neck will not need to be stabilized following a cauda equina injury,which affects the lumbar and sacral nerve roots.

Question 3

Which action will the nurse take when caring for a 46-year-old patient who develops tetanus from an injectable substance use?

Accepted Answer

In patients with tetanus,painful seizures can be precipitated by jarring,loud noises,or bright lights,so the nurse will minimize noise and avoid shining light into the patient's eyes.Range-of-motion exercises may also stimulate the patient and cause seizures.Although the patient has a history of injectable drug use,sedative medications will be needed to decrease spasms.

Question 4

In which order will the nurse perform the following actions when caring for a patient with possible C5 spinal cord trauma who is admitted to the emergency department? (Put a comma and a space between each answer choice [A,B,C,D,E].)

Accepted Answer

The first action should be to prevent further injury by stabilizing the patient's spinal cord if the patient does not have penetrating trauma.Maintenance of oxygenation by administration of 100% O? is the second priority.Because neurogenic shock is a possible complication,monitoring of heart rhythm and BP are indicated,followed by infusing normal saline for volume replacement.A CT scan to determine the extent and level of injury is needed once initial assessment and stabilization are accomplished.

Question 5

Which of these nursing actions for a 64-year-old patient with Guillain-Barré syndrome is most appropriate for the nurse to delegate to an experienced unlicensed assistive personnel (UAP)?

Accepted Answer

Assisting a patient with movement is included in UAP education and scope of practice.Administration of tube feedings,administration of ordered medications,and assessment are skills requiring more education and scope of practice,and the RN should perform these skills.

Question 6

When caring for a patient who experienced a T₂ spinal cord transection 24 hours ago,which collaborative and nursing actions will the nurse include in the plan of care (select all that apply)?

Accepted Answer

The patient is at risk for bradycardia and poikilothermia caused by sympathetic nervous system dysfunction and should have continuous cardiac monitoring and maintenance of a relatively warm room temperature.Gastrointestinal (GI)motility is decreased initially and NG suctioning is indicated.To avoid bladder distention,a urinary retention catheter is used during this acute phase.Stress ulcers are a common complication,but can be avoided through the use of the H₂ receptor blockers such as famotidine.

Question 7

A patient with neurogenic shock following a spinal cord injury is to receive lactated Ringer's solution 500 mL over 30 minutes.When setting the IV pump to deliver the IV fluid,the nurse will set the rate at how many mL/hour?

Accepted Answer

The answer of A patient with neurogenic shock following a...

Question 8

A patient admitted with dermal ulcers who has a history of a T₃spinal cord injury tells the nurse,"I have a pounding headache and I feel sick to my stomach." Which action should the nurse take first?

Accepted Answer

The BP should be assessed immediately in a patient with an injury at the T6 level or higher who complains of a headache to determine whether autonomic dysreflexia is occurring.Notification of the patient's health care provider is appropriate after the BP is obtained.Administration of an antiemetic is indicated after autonomic dysreflexia is ruled out as the cause of the nausea.After checking the BP,the nurse may assess for a fecal impaction using lidocaine jelly to prevent further increased BP.

Question 9

A patient who had a C7 spinal cord injury a week ago has a weak cough effort and audible rhonchi.The initial intervention by the nurse should be to

Accepted Answer

Because the cough effort is poor,the initial action should be to use assisted coughing techniques to improve the ability to mobilize secretions.Administration of oxygen will improve oxygenation,but the data do not indicate hypoxemia.The use of the spirometer may improve respiratory status,but the patient's ability to take deep breaths is limited by the loss of intercostal muscle function.Suctioning may be needed if the patient is unable to expel secretions by coughing but should not be the nurse's first action.

Question 10

Which finding in a patient with a spinal cord tumor is most important for the nurse to report to the health care provider?

Accepted Answer

Decreasing sensation and leg movement indicates spinal cord compression,an emergency that will require rapid action (such as surgery)to prevent paralysis.The other findings will also require nursing action but are not emergencies.

Question 11

A 33-year-old patient with a T4 spinal cord injury asks the nurse whether he will be able to be sexually active.Which initial response by the nurse is best?

Accepted Answer

Although sexuality will be changed by the patient's spinal cord injury,there are options for expression of sexuality and for fertility.The other information also is correct,but the choices will depend on the degrees of injury and the patient's individual feelings about sexuality.

Question 12

Before administering botulinum antitoxin to a patient in the emergency department,it is most important for the nurse to

Accepted Answer

To assess for possible allergic reactions,an intradermal test dose of the antitoxin should be administered.Although temperature,allergy history,and symptom assessment and documentation are appropriate,these assessments will not affect the decision to administer the antitoxin.

Question 13

A 39-year-old patient is being evaluated for a possible spinal cord tumor.Which finding by the nurse requires the most immediate action?

Accepted Answer

The new onset of symptoms indicates cord compression,which is an emergency that requires rapid treatment to avoid permanent loss of function.The other patient assessments also indicate a need for nursing action but do not require intervention as rapidly as the new onset weakness.

Quiz 57: Nursing Management: Peripheral Nerve and Spinal Cord Problems

A nurse who works on the neurology unit just received change-of-shift report.Which patient will the nurse assess first?

Following a cauda equina spinal cord injury,which action will the nurse include in the plan of care?

Which action will the nurse take when caring for a 46-year-old patient who develops tetanus from an injectable substance use?

In which order will the nurse perform the following actions when caring for a patient with possible C5 spinal cord trauma who is admitted to the emergency department? (Put a comma and a space between each answer choice [A,B,C,D,E].)

Which of these nursing actions for a 64-year-old patient with Guillain-Barré syndrome is most appropriate for the nurse to delegate to an experienced unlicensed assistive personnel (UAP) ?

When caring for a patient who experienced a T₂ spinal cord transection 24 hours ago,which collaborative and nursing actions will the nurse include in the plan of care (select all that apply) ?

A patient with neurogenic shock following a spinal cord injury is to receive lactated Ringer's solution 500 mL over 30 minutes.When setting the IV pump to deliver the IV fluid,the nurse will set the rate at how many mL/hour?

A patient admitted with dermal ulcers who has a history of a T₃spinal cord injury tells the nurse,"I have a pounding headache and I feel sick to my stomach." Which action should the nurse take first?

A patient who had a C7 spinal cord injury a week ago has a weak cough effort and audible rhonchi.The initial intervention by the nurse should be to

Which finding in a patient with a spinal cord tumor is most important for the nurse to report to the health care provider?

A 33-year-old patient with a T4 spinal cord injury asks the nurse whether he will be able to be sexually active.Which initial response by the nurse is best?

Before administering botulinum antitoxin to a patient in the emergency department,it is most important for the nurse to

A 39-year-old patient is being evaluated for a possible spinal cord tumor.Which finding by the nurse requires the most immediate action?

Quiz 57: Nursing Management: Peripheral Nerve and Spinal Cord Problems

A nurse who works on the neurology unit just received change-of-shift report.Which patient will the nurse assess first?

Following a cauda equina spinal cord injury,which action will the nurse include in the plan of care?

Which action will the nurse take when caring for a 46-year-old patient who develops tetanus from an injectable substance use?

In which order will the nurse perform the following actions when caring for a patient with possible C5 spinal cord trauma who is admitted to the emergency department? (Put a comma and a space between each answer choice [A,B,C,D,E].)

Which of these nursing actions for a 64-year-old patient with Guillain-Barré syndrome is most appropriate for the nurse to delegate to an experienced unlicensed assistive personnel (UAP) ?

When caring for a patient who experienced a T2 spinal cord transection 24 hours ago,which collaborative and nursing actions will the nurse include in the plan of care (select all that apply) ?

A patient with neurogenic shock following a spinal cord injury is to receive lactated Ringer's solution 500 mL over 30 minutes.When setting the IV pump to deliver the IV fluid,the nurse will set the rate at how many mL/hour?

A patient admitted with dermal ulcers who has a history of a T3 spinal cord injury tells the nurse,"I have a pounding headache and I feel sick to my stomach." Which action should the nurse take first?

A patient who had a C7 spinal cord injury a week ago has a weak cough effort and audible rhonchi.The initial intervention by the nurse should be to

Which finding in a patient with a spinal cord tumor is most important for the nurse to report to the health care provider?

A 33-year-old patient with a T4 spinal cord injury asks the nurse whether he will be able to be sexually active.Which initial response by the nurse is best?

Before administering botulinum antitoxin to a patient in the emergency department,it is most important for the nurse to

A 39-year-old patient is being evaluated for a possible spinal cord tumor.Which finding by the nurse requires the most immediate action?

When caring for a patient who experienced a T₂ spinal cord transection 24 hours ago,which collaborative and nursing actions will the nurse include in the plan of care (select all that apply) ?

A patient admitted with dermal ulcers who has a history of a T₃spinal cord injury tells the nurse,"I have a pounding headache and I feel sick to my stomach." Which action should the nurse take first?