Question 1

A client who has a lower motor neuron injury experiences a flaccid bowel elimination pattern.Which action does the nurse implement to assist in relieving this client's constipation?

Accepted Answer

For the client with a lower motor neuron injury,the resulting flaccid bowel may require a bowel program for the client,which includes stool softeners,increased fluid intake,a high-fiber diet,and a consistent elimination time.The other interventions do not assist this client.

Question 2

A client with paraplegia is scheduled to participate in a rehabilitation program.The client states,"I do not understand the need for rehabilitation; the paralysis will not go away and it will not get better." How does the nurse respond?

Accepted Answer

Participation in rehabilitation programs has many purposes,including prevention of disability,maintenance of functional ability,and restoration of function.The other responses do not meet the client's needs.

Question 3

Emergency medical services arrive to the emergency department with a client who has a cervical spinal cord injury.Which priority assessment does the emergency department nurse perform at this time?

Accepted Answer

The first priority for a client with a spinal cord injury is assessment of respiratory status and airway patency.Clients with cervical spine injuries are particularly prone to respiratory compromise and may even require intubation.The other assessments should be performed after airway and breathing are assessed.

Question 4

A client presents with an acute exacerbation of multiple sclerosis.Which prescribed medication does the nurse prepare to administer?

Accepted Answer

Methylprednisolone is the drug of choice for acute exacerbations of the disease.The other medications are not appropriate.

Question 5

The nurse is assessing a client with an early onset of multiple sclerosis (MS).Which clinical manifestation does the nurse expect to see?

Accepted Answer

Early signs and symptoms of MS include changes in motor skills,vision,and sensation.The other manifestations are later signs of MS.

Question 6

A client who has a herniated disk is being discharged after a percutaneous endoscopic discectomy.Which postprocedure instructions does the nurse provide before discharge?

Accepted Answer

After this minimally invasive surgery,clients typically go home the same day or the day after surgery.Clients should be taught to begin the prescribed exercise program immediately after discharge,which includes walking every day.The client should not be restricted to one sleeping position.Clients generally have less pain with this procedure and do not experience numbness or tingling.The client may have a clear or gauze dressing but will not need to wear a lumbar brace.

Question 7

The nurse assesses for which clinical manifestation in a client with multiple sclerosis (MS)of the relapsing type?

Accepted Answer

The classic picture of relapsing-remitting MS is characterized by increasingly frequent attacks.The other manifestations do not correlate with a relapsing type of MS.

Question 8

The nurse is caring for a client who has undergone a spinal fusion.Which specific postoperative instructions does the nurse give this client?

Accepted Answer

Clients who undergo spinal fusion are fitted with a brace that they need to wear throughout the healing process (usually 3 to 6 months)whenever they are out of bed.The client does not need to remain on bedrest for the first 48 hours,should not lift anything,and will not take steroids for rejection prevention.

Question 9

The nurse notes reddened areas over the hips and sacrum of a client with paraplegia from a spinal cord injury.Which action does the nurse implement?

Accepted Answer

Reddened areas should not be rubbed because this action could cause more extensive damage to the already fragile capillary system.ROM exercises are used to prevent contractures.The reddened areas should be assessed for blanching.If the skin does not blanch,the area is vulnerable to breakdown.Appropriate interventions to relieve pressure on these areas through positioning,assistive devices,and skin protection should then be used.

Question 10

The nurse is teaching a client who has a spinal cord injury how to prevent respiratory problems at home.Which statement indicates that the client correctly understands the teaching?

Accepted Answer

Often,the person with a spinal cord injury will have weak intercostal muscles and is at higher risk for developing atelectasis and stasis pneumonia.Using an incentive spirometer every 2 hours helps the client expand her or his lungs more fully and prevents atelectasis.Clients should drink fluids that they can tolerate; usually thick fluids are easy to tolerate.The client should be encouraged to cough and clear secretions.Clients should be placed in high Fowler's position to prevent aspiration.

Question 11

A client who suffered a spinal cord injury at level T5 several months ago develops a flushed face and blurred vision.On taking vital signs,the nurse notes the blood pressure to be 184/95 mm Hg.Which is the nurse's first action?

Accepted Answer

The client is manifesting symptoms of autonomic dysreflexia.Common causes include bladder distention,tight clothing,increased room temperature,and fecal impaction.If persistent,the client could experience neurologic injury.Precipitating conditions should be eliminated and the physician notified.The other actions would not be appropriate.

Question 12

The nurse is assessing a client who had a discectomy 6 hours ago.Which client complaint requires priority action by the nurse?

Accepted Answer

Inability to void may indicate damage to the sacral spinal nerves.The other symptoms require the nurse to provide care but are not the priority or a complication of the procedure.

Question 13

The nurse is providing discharge teaching to a client after a lumbar laminectomy.For which complication does the nurse instruct the client to return to the hospital?

Accepted Answer

The finding of clear fluid on the dressing after a laminectomy strongly suggests a cerebrospinal fluid leak,which constitutes an emergency.The client has in increased risk of meningitis with a spinal fluid leak.Pain,redness,and itching at the site are normal.The client should be encouraged to eat a healthy diet but does not need to return to the hospital for a decreased appetite.

Question 14

The nurse is caring for a client who has low back pain (LBP)from a work-related injury.Which measures does the nurse incorporate into the client's plan of care?

Accepted Answer

Heat increases blood flow to the affected area and promotes healing of injured nerves.However,continuous application of moist heat can promote skin breakdown.

Question 15

The nurse is caring for a client who has a vertebral fracture.Which intervention does the nurse implement to prevent deterioration of the client's neurologic status?

Accepted Answer

The nurse keeps the client in optimal body alignment at all times,avoiding flexion and extension at the site of vertebral injury,to prevent further cord injury or irritability from bone fragments.A brace,traction,or external fixation may be used for this purpose.The other interventions would not prevent deterioration of the client's neurologic status.Assessments would assist with the recognition of neurologic changes but would not prevent them.

Question 16

The nurse is providing health education at a community center.Which instruction does the nurse include as part of client education for the prevention of low back pain?

Accepted Answer

Exercise can strengthen back muscles,reducing the incidence of low back pain.The other options will not prevent low back pain.

Question 17

A client with multiple sclerosis is being treated with fingolimod (Gilenya).Which clinical manifestation alerts the nurse to an adverse effect of this medication?

Accepted Answer

Fingolimod (Gilenya)is an antineoplastic agent that can cause bradycardia,especially within the first 6 hours after administration.The other manifestations are not adverse effects of fingolimod.

Question 18

The nurse is assessing a client with a spinal cord injury at the T5 level.Which clinical manifestation alerts the nurse to the presence of a complication of this injury?

Accepted Answer

Clients with injuries at or above the T6 vertebra are especially at risk for respiratory complications caused by impaired intercostal muscles.The development of fever and cough should alert the nurse to the possibility of pneumonia.The other manifestations are not related to complications from this type of injury.

Question 19

A client who experienced a spinal cord injury 1 hour ago is brought to the emergency department.Which prescribed medication does the nurse prepare to administer to this client?

Accepted Answer

Methylprednisolone (Medrol)should be given within 8 hours of the injury.Clients who receive this therapy usually show improvement in motor and sensory function.The other medications are inappropriate for the client.

Question 20

The nurse is caring for a client with a lower motor neuron lesion who wishes to achieve bladder control.Which intervention does the nurse implement to effectively stimulate the initiation of voiding for this client?

Accepted Answer

In clients with lower motor neuron problems,such as spinal cord injury,performing a Valsalva maneuver or tightening the abdominal muscles are interventions that can initiate voiding.The other interventions do not initiate voiding.

Quiz 45: Care of Patients With Problems of the Central Nervous System: the Spinal Cord