Question 1

A client diagnosed with Bell's palsy asks the nurse why eye drops have been prescribed. Which of the following should the nurse respond to this client?

Accepted Answer

Bell's palsy can cause facial muscle weakness or paralysis, including the muscle that closes the eyelid. This can lead to dry eyes and potential damage to the cornea. Eye drops help to lubricate and protect the eyes from damage due to dryness. Therefore, option A is the correct response as it provides the rationale behind why eye drops have been prescribed. Option B is incorrect as Bell's palsy does not affect tear production, and option C is incorrect as dust trapping is not a concern in this situation. Option D is incorrect as eye drops are commonly prescribed in Bell's palsy to prevent eye damage.

Question 2

The nurse is preparing a community education program on the prevention of spinal cord injuries. Which of the following individuals would most likely benefit from this education?

Accepted Answer

The adolescent male who rides horses is most likely to benefit from education on the prevention of spinal cord injuries, as horseback riding is a high-risk activity for such injuries. Adolescents and males in general are also more frequently affected by spinal cord injuries compared to females or older adults, increasing their risk of injury.

Question 3

The nurse, planning care for a client diagnosed with a spinal cord injury, would include interventions to address autonomic dysreflexia because the client's spinal cord injury is at which of the following levels?

Accepted Answer

Autonomic dysreflexia occurs in clients with spinal cord injuries at or above the T6 level. The T4 level is above T6 and therefore the interventions for autonomic dysreflexia would be necessary. L5, S1, and T12 are not at or above the T6 level.

Question 4

A client experienced a spinal cord injury during a football game. The paramedics applied a neck brace prior to moving the client onto a hard board for transportation. The nurse realizes that the neck brace was provided because the area of the spinal cord most vulnerable to injury is:

Accepted Answer

The most vulnerable area of the spinal cord is the cervical region, which is located in the neck. The use of a neck brace is meant to stabilize the cervical spine to prevent further damage or injury during transportation.

Question 5

The nurse is preparing to administer high-dose methylprednisolone to a client diagnosed with a spinal cord injury. The nurse realizes that for this medication to be most effective treatment should begin:

Accepted Answer

High-dose methylprednisolone is recommended to be given within 8 hours of spinal cord injury to have the most effective treatment outcome. Delayed administration of the drug beyond 8 hours has not shown significant benefit in improving neurological outcomes.

Question 6

A client is diagnosed with a peripheral nerve injury. Which of the following will the nurse most likely assess in this client? (Select all that apply.)

Accepted Answer

Peripheral nerve injury can cause a variety of sensory and motor deficits, including paresthesias (abnormal sensations like tingling or numbness), paralysis, paresis (partial weakness), and pain. Hypotension and cardiac dysrhythmias are not typically associated with peripheral nerve injury.

Question 7

The nurse realizes that most spinal cord injuries are caused by: (Select all that apply.)

Accepted Answer

Falls, motor vehicle crashes, sports injuries, and gunshot wounds are the most common causes of spinal cord injuries.

Question 8

A client is diagnosed with Bell's palsy. Which of the following will the nurse most likely assess in this client?

Accepted Answer

The answer of A client is diagnosed with Bell's palsy....

Question 9

The nurse is caring for a client receiving radiation for a spinal cord tumor. The nurse realizes that interventions need to be planned to address which of the following potential complications of this treatment? (Select all that apply.)

Accepted Answer

Radiation treatment for a spinal cord tumor may cause increasing neurological impairment, paralysis, and loss of bowel and bladder function, as the radiation may damage the surrounding tissue and nerves. Decubitus ulcers and peripheral vascular disease are not typically associated with radiation treatment for a spinal cord tumor. Osteoporosis may be a potential long-term complication, but it is not an immediate concern during treatment.

Question 10

A client diagnosed with a spinal cord tumor is being prepared for treatment. The nurse realizes that treatment will include irradiation along with which of the following?

Accepted Answer

Irradiation can cause swelling in the spinal cord, so treatment often includes steroids like dexamethasone to reduce inflammation and prevent further damage. Tylenol and Vicodin are pain medications, and Reglan is an anti-nausea medication, which may be used for supportive care but are not directly involved in treating the tumor.

Question 11

A client diagnosed with a spinal cord injury has been experiencing spinal shock. Which of the following assessment findings would indicate that this shock is resolving?

Accepted Answer

Reflexive emptying of the bladder indicates the return of autonomic reflexes, which is a sign that spinal shock is resolving. The other options are not necessarily specific to the resolution of spinal shock.

Question 12

A client is being evaluated for the presence of carpal tunnel syndrome. Which of the following diagnostic tests will be used to aid in the diagnosis of this disorder? (Select all that apply.)

Accepted Answer

Electromyography (A) assesses the electrical activity of muscles and can help diagnose carpal tunnel syndrome. Tinel's sign (E) and Phalen's sign (F) are clinical tests specifically used to diagnose carpal tunnel syndrome by eliciting symptoms.

Question 13

A client receiving care for a spinal cord injury complains of a pounding headache, blurred vision, and has a blood pressure of 200/100 mmHg. What is the first action the nurse should take?

Accepted Answer

The client's headache and elevated blood pressure could indicate autonomic dysreflexia, which is a potentially life-threatening emergency that can be triggered by bladder distension. The nurse should check the client's bladder for distension and take steps to relieve it if it is present. Administering pain medication or positioning the client on the left side will not address the underlying cause of the symptoms, and turning off the lights and decreasing noise may be helpful for comfort but will not address the potentially life-threatening situation.

Question 14

The nurse is caring for a client with a spinal cord injury located at T

Accepted Answer

Pulmonary complications, such as ineffective cough and pneumonia, are common in clients with spinal cord injury at the thoracic level. The nurse should assist with removal of pulmonary secretions to prevent respiratory complications.

Answer: A
 Depending on the level and severity of the spinal cord injury, the client may require mechanical ventilation to maintain adequate respiratory function.

Answer: B
 A spinal cord injury at the thoracic level may affect the functioning of the pancreas and increase the risk of developing diabetes. The nurse should monitor blood glucose levels and collaborate with the healthcare provider if necessary.

Answer: D
 Clients with a spinal cord injury at the thoracic level may not be able to walk or ambulate without assistive devices, such as a wheelchair or crutches. However, this is not the priority intervention and the other options are more crucial in the immediate care of the client.

Therefore, options A, B, and C should be included in the client's plan of care, while option D may also be included but is not the priority.

Question 15

A client is recovering from a spinal cord injury at level T

Accepted Answer

The answer of A client is recovering from a spinal...

Question 16

A client is diagnosed with Guillain-Barré syndrome. The nurse would assess that signs and symptoms of the disorder would appear in which of the following order?

Accepted Answer

Guillain-Barré syndrome typically starts with weakness or tingling sensations in the legs that can then progress upward to the arms, upper body, and even breathing muscles. Therefore, option C is the correct order of appearance of signs and symptoms.

Question 17

The nurse is determining diagnoses appropriate for a client newly diagnosed with Guillian-Barré syndrome. Which of the following nursing diagnoses would be appropriate for this client?

Accepted Answer

Guillain-Barré syndrome can lead to muscle weakness and paralysis, which can affect the respiratory muscles, leading to an ineffective breathing pattern.

Question 18

Which of the following should the nurse instruct a client diagnosed with trigeminal neuralgia to help control symptoms?

Accepted Answer

Trigeminal neuralgia is a condition that causes severe facial pain due to irritation or damage to the trigeminal nerve. Clients with this condition should avoid extreme temperature variances in food and drink, as this can trigger an episode of pain. Active range-of-motion exercises or staying in bed with little movement would not directly impact the symptoms of trigeminal neuralgia. While staying hydrated is important for overall health, drinking eight glasses of water a day would not specifically help control symptoms of trigeminal neuralgia.

Quiz 36: Dysfunction of the Spinal Cord and Peripheral Nervous System: Nursing Management