Question 1

The nurse is aware that which one of the following is the most common cause of premature death in a patient with tetraplegia?

Accepted Answer

Pneumonia is the most common cause of premature death in patients with tetraplegia due to the higher risk of respiratory complications and infections associated with paralysis of the muscles responsible for coughing and clearing respiratory secretions. Diabetes, acute renal failure, and hypertension can contribute to morbidity and mortality in tetraplegic patients but are not as common as pneumonia.

Question 2

A patient with a paraplegia resulting from a T10 spinal cord injury has a neurogenic reflex bladder.The nurse consults with the physician regarding bladder management,recommending that which of the following initial treatments should be included?

Accepted Answer

Intermittent catheterization every 4 hours is the appropriate initial treatment for a patient with neurogenic reflex bladder as it allows for timely and effective bladder emptying, reducing the risk of urinary tract infections and bladder distention. Limiting fluid intake or clamping a Foley catheter are not appropriate interventions as they can lead to dehydration or bladder damage. Catheterization for residual urine after each voiding may be indicated in some cases but is not typically the initial treatment.

Question 3

A patient with a spinal cord transection at T1 is in spinal shock.While monitoring the patient,the nurse recognizes that alterations in sympathetic nervous system function may cause which of the following reactions?

Accepted Answer

Spinal shock can lead to loss of sympathetic tone below the level of injury, causing issues with thermoregulation and resulting in fluctuating body temperature.

Question 4

A patient with Guillain-Barré syndrome asks the nurse what has caused the disease.In responding to the patient,what should the nurse explain about Guillain-Barré syndrome?

Accepted Answer

Guillain-Barré syndrome is believed to be an autoimmune disorder in which the patient's immune system mistakenly attacks the protective covering of peripheral nerves, causing inflammation and damage to the nerves. This can result in muscle weakness, paralysis, and other neurological symptoms. There is no single known cause of the syndrome, but it is often triggered by a viral or bacterial infection.

Question 5

The physician orders administration of IV methylprednisolone for the first 24 hours to a patient who experienced a spinal cord injury 3 hours ago.What will the nurse assess when evaluating the effectiveness of this drug?

Accepted Answer

Methylprednisolone is used to treat spinal cord injuries by reducing inflammation and preventing further damage. The nurse should assess the patient's motor and sensory function of the legs, as improvement in these areas indicates the drug is effective in reducing spinal cord damage. Assessing blood pressure, heart rate, respiratory effort, O2 saturation, bowel sounds, and abdominal distension may all be important aspects of patient care, but they do not specifically evaluate the effectiveness of methylprednisolone for spinal cord injury.

Question 6

When planning care for a patient during an acute episode of trigeminal neuralgia,what is an appropriate intervention to include?

Accepted Answer

When a patient is experiencing an acute episode of trigeminal neuralgia, evaluating their hydration and nutrition status is an appropriate intervention as these factors can impact their overall health and wellbeing. It is important to ensure the patient is adequately hydrated and receiving proper nutrition to support their recovery. Exercise of the muscles of the face and jaw, regular exercise regimen, and application of ice packs to the affected area are not appropriate interventions for trigeminal neuralgia during an acute episode.

Question 7

When caring for a patient who had a C8 spinal cord injury 10 days ago and has a weak cough effort,bibasilar crackles,and decreased breath sounds,the initial nursing intervention should be to do which of the following?

Accepted Answer

CFor a patient with a C8 spinal cord injury and weak cough effort, placing hands on the epigastric area and pushing upward when the patient coughs (B) can help increase the effectiveness of the cough by providing additional expiratory force. Encouraging the use of an incentive spirometer every 2 hours during the day (C) helps improve lung expansion and prevents atelectasis, which is crucial for a patient with decreased breath sounds and bibasilar crackles.

Question 8

A patient with Bell's palsy refuses to eat while others are present.What is the best response to the patient's behaviour?

Accepted Answer

As a healthcare professional, it is important to respect the patient's wishes for privacy and not force them to eat in the presence of others. It is important to discuss alternative options such as providing a private space for the patient to eat, rather than pushing them to eat in front of others.

Question 9

When assessing a patient with newly diagnosed trigeminal neuralgia,the nurse will ask the patient about which of the following?

Accepted Answer

Trigeminal neuralgia is characterized by severe facial pain, often triggered by certain actions such as eating, talking, or touching the affected area. Therefore, it is important for the nurse to ask the patient about potential triggers that exacerbate the pain. Visual problems and a decreased sensation may not necessarily be associated with trigeminal neuralgia, while poor appetite is unlikely to be caused by a loss of taste specifically in this scenario.

Question 10

A patient arrives at an urgent care centre after stepping on a nail that was embedded in some old lumber in a field.The patient reports having had a tetanus booster 7 years ago.What will the nurse anticipate for care?

Accepted Answer

The best choice would be to administer the Td toxoid booster. A tetanus booster is recommended every 10 years, so the patient is due for a booster. However, if it has been more than 5 years since the last booster and the wound is contaminated, it is recommended to administer the booster immediately. IV infusion of tetanus immune globulin is reserved for individuals who have not received a tetanus booster in over 5 years and have a contaminated wound. Intradermal injection of an immune globulin test dose is not necessary in this case as the patient reports having had a tetanus booster 7 years ago. Initiating the tetanus-diphtheria (Td) immunization series is not necessary as the patient has already received a booster.

Question 11

When caring for a patient who has Guillain-Barré syndrome,which assessment data obtained by the nurse will require the most immediate action?

Accepted Answer

Continuous drooling of saliva may indicate respiratory distress or difficulty swallowing and require immediate action to prevent aspiration. Severe tingling pain in the feet, hypotension, and absent reflexes are common manifestations of Guillain-Barré syndrome, but do not require immediate intervention.

Question 12

A patient admitted to the emergency department is diagnosed with botulism poisoning,and botulinum antitoxin is to be administered.Before administration of the antitoxin,what should the nurse do?

Accepted Answer

An intradermal test dose is administered to check for any allergic reaction to the antitoxin before giving the full dose.

Question 13

As a result of a gunshot wound,a patient has an incomplete right 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

Positioning the patient's right leg when turning the patient is important in Brown-Séquard syndrome as there is paralysis on one side of the body and loss of sensation on the other. The nurse should always be mindful of protecting the affected limbs while repositioning or turning the patient. Assessing for left leg pain and left arm weakness may not be necessary as these are not typically associated with Brown-Séquard syndrome. Teaching the patient to look at the left leg to verify its position may not be feasible or practical, especially if the patient has visual impairments or limited mobility.

Question 14

When teaching patients who are at risk for Bell's palsy because of previous herpes simplex infection,which information should the nurse include?

Accepted Answer

The nurse should instruct patients to notify their doctor if they experience pain or herpes lesions near their ear as this can be a warning sign of Bell's palsy. However, antiviral agents do not prevent Bell's palsy and medications for Bell's palsy must be started within a certain timeframe after onset, so choices B and C are incorrect. Facial exercises may not necessarily prevent Bell's palsy, so choice D is also incorrect.

Question 15

A 24-year-old patient is hospitalized with the onset of Guillain-Barré syndrome.During this phase of the patient's illness,what is the most essential assessment for the nurse to carry out?

Accepted Answer

Guillain-Barré syndrome can lead to respiratory failure due to progressive weakness of the respiratory muscles, so constant evaluation of respiratory function is critical. While monitoring vital signs, determining level of consciousness, and evaluating sensory and motor function are important, they are not as essential as monitoring respiratory function in this patient population.

Question 16

A patient with a cervical neck fracture at the C5 level is admitted to the critical care unit following initial treatment in the emergency department.During initial assessment of the patient,the nurse recognizes the presence of spinal shock on finding which of the following data?

Accepted Answer

Spinal shock is a transient, but potentially prolonged period of physiological reflex depression that can develop after a spinal cord injury. It can lead to temporary loss of reflexes, flaccid paralysis, and decreased sensation below the level of the injury. Hypotension, bradycardia, and warm extremities are signs of neurogenic shock. Involuntary, spastic movements of the arms and legs and the presence of reflex activity below the level of the injury would suggest that spinal shock has resolved and spasticity has set in.

Question 17

During assessment of the patient with a recurrence of symptoms of trigeminal neuralgia,what should the nurse do?

Accepted Answer

The nurse should examine the oral cavity for the state of hygiene because poor oral hygiene can be a trigger for trigeminal neuralgia.

Question 18

During the initial phase of care for a patient with spinal cord trauma at C5,why must the nurse give high priority to maintaining respiratory function?

Accepted Answer

Extension of edema above the site of the injury may affect phrenic nerve function, which is responsible for diaphragmatic movement and thus critical for breathing.

Question 19

A patient with a long history of trigeminal neuralgia recently had a glycerol rhizotomy for control of symptoms.During a follow-up visit after the rhizotomy,what finding indicates to the nurse that the patient has made a successful adjustment to the surgical intervention?

Accepted Answer

The patient returning to previous interpersonal and social relationships with family and friends indicates that they are no longer experiencing the debilitating pain and discomfort associated with trigeminal neuralgia. This suggests that the glycerol rhizotomy was successful in controlling their symptoms. The other options are not necessarily indicators of successful adjustment to the surgical intervention. Using an eye shield may be a precautionary measure to prevent injury, but it does not indicate whether the patient's symptoms have been alleviated. Facial exercises and chewing on the unaffected side of the mouth may be useful strategies for managing residual symptoms, but they do not necessarily reflect a successful adjustment to the surgical intervention.

Question 20

A 45-year-old woman is hospitalized with Guillain-Barré syndrome.What treatment will the nurse explain will most likely be included during the first 2 to 3 weeks of her illness?

Accepted Answer

The administration of immune globulin (Sandoglobulin) is the most likely treatment during the first 2 to 3 weeks of Guillain-Barré syndrome. This treatment helps suppress the immune system's attack on the peripheral nerves, reducing inflammation and damage. Hemodialysis and mechanical ventilation are not typically used in the treatment of Guillain-Barré syndrome. Administration of methylprednisolone (Solu-Medrol) may be considered but is not as effective as immune globulin therapy.

Quiz 63: Nursing Management: Peripheral Nerve and Spinal Cord Problems