Chapter 19 My Nursing Test Banks

Wagner, High Acuity Nursing, 6e
Chapter 19

Question 1

Type: MCSA

A patient is admitted for a lumbar laminectomy. The nurse reinforces teaching that which portion of the vertebra will be removed?

1. Roof of the arch

2. Cartilage inside the vertebra

3. Pedicles that attach the arch to the body

4. Spinous process

Correct Answer: 1

Rationale 1: Each vertebra consists of a body that is anterior and an arch that is posterior. The arch section is composed of two pedicles that attach the arch to the body and two laminae that form the roof of the arch.

Rationale 2: Cartilage is not a part of the vertebra.

Rationale 3: The pedicles attach the arch to the body of the vertebra. This is not the site of a laminectomy.

Rationale 4: The spinous process is located at the rear of the vertebrae. This is not the site of the laminae.

Global Rationale: 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 19-1

Question 2

Type: MCSA

A patient is diagnosed with a fracture of anterior and posterior columns of three cervical vertebrae. How would the nurse describe this injury?

1. As life threatening

2. As stable

3. As minor

4. As unstable

Correct Answer: 4

Rationale 1: In itself, this injury is not life threatening. If secondary damage occurs, it could become life threatening.

Rationale 2: This injury is significant and would not be considered stable.

Rationale 3: Damage to two columns of three vertebrae is not a minor injury.

Rationale 4: The spine is conceptualized as having three columns: an anterior column that includes the anterior part of the vertebral body, a middle column that houses the posterior wall of the vertebral body, and a posterior column that includes the vertebral arch. If two or more of these columns are damaged, the injury is considered to be unstable. The patient has an unstable spinal cord injury.

Global Rationale: 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 19-1

Question 3

Type: MCSA

A patient is diagnosed with damage to the spinothalamic tract of the spinal cord. Which assessment finding would the nurse attribute to this damage?

1. The patient reports an unusual amount of pain.

2. Muscle spasms are occurring in the patients right leg.

3. The patient has ataxia.

4. The patient is complaining of vertigo.

Correct Answer: 1

Rationale 1: The spinothalamic tract originates in the spinal cord, crosses over with segments of entry and ascends to the thalamus in the brain. It transmits pain and temperature. The patient with damage to the spinothalamic tract of the spinal cord will manifest an unusual amount of pain.

Rationale 2: The corticospinal tract originates in the brain and crosses over in the brainstem to innervate the opposite side of the body. It transmits motor activity, which would be the cause for the muscle spasms in the patient.

Rationale 3: The posterior horn contains axons from the peripheral sensory neurons and is responsible for position sense. Damage to this portion of the cord could manifest as ataxia.

Rationale 4: The posterior horn contains axons from the peripheral sensory neurons and is responsible for position sense. Damage to this portion of the cord could manifest as vertigo in the patient.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 19-1

Question 4

Type: MCSA

The nurse is caring for a patient with a fractured sacrum. The nurse would assess for which changes as a result of this fracture?

1. Altered sympathetic responses

2. Alteration in pain responses

3. Alteration in position sense

4. Altered parasympathetic responses

Correct Answer: 4

Rationale 1: The sympathetic nervous system is located in the gray matter of the first thoracic through the second lumbar section of the cord. The patient does not have an injury to this region.

Rationale 2: Alteration in pain responses would be seen with damage to the spinothalamic tracts.

Rationale 3: Alteration in position sense would be seen with damage to the posterior column tracts.

Rationale 4: The parasympathetic nervous system originates in a group of neurons located in the brainstem and in a group located between the second and fourth sacral segments of the cord. The patient with a fractured sacrum could experience alterations in the parasympathetic responses.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 19-1

Question 5

Type: MCSA

A patient is diagnosed with central cord syndrome. Which assessment finding would the nurse anticipate from this injury?

1. Complete paralysis of lower extremities

2. Loss of bladder and bowel function

3. Motor function intact in upper extremities

4. Variable motor function in lower extremities

Correct Answer: 4

Rationale 1: Complete paralysis of lower extremities does not result from central cord syndrome.

Rationale 2: Patients with central cord injury typically retain some bladder and bowel function.

Rationale 3: The upper extremities will demonstrate spastic paralysis and not an intact upper extremity motor status.

Rationale 4: In central cord syndrome the patient will demonstrate variable motor function of the lower extremities.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 19-2

Question 6

Type: MCSA

A patient comes into the emergency department after being injured in an automobile crash in which a semi-truck hit her car from behind. The nurse will assess this patient for findings associated with which type of injury?

1. Ankylosing spondylitis

2. Axial loading

3. Hyperflexion

4. Hyperextension

Correct Answer: 4

Rationale 1: Ankylosing spondylitis can cause a nontraumatic hyperextension injury.

Rationale 2: Axial loading injury, or compression fracture, is caused by a vertical force along the spinal cord and is seen after diving into shallow water or jumping from tall heights and landing on the feet or buttocks.

Rationale 3: Hyperflexion injury is most often caused by a sudden deceleration of the motion of the head or a head-on collision.

Rationale 4: Hyperextension injuries are caused by a forward and backward motion of the head as seen in rear-end collisions. With this injury, the anterior ligaments are torn and the spinal cord is stretched. A mild form of hyperextension injury is the whiplash injury.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 19-2

Question 7

Type: MCSA

A patient was admitted this morning after sustaining an acute spinal cord injury. This afternoon his neurological assessment shows some deterioration of function. How would the nurse explain this to the patients family?

1. Injured cells release potassium that causes destruction of the covering of nerves in the area injured.

2. Decreased blood flow increases the size of the affected area.

3. The bodys inflammatory response has caused blood vessels in the area to dilate.

4. Injury to nerves impairs the bodys healing responses.

Correct Answer: 2

Rationale 1: Calcium is released in a spinal cord injury and is responsible for demyelization.

Rationale 2: Blood flow to the spinal cord decreases immediately on injury as a result of hypotension and vasospasm induced thrombosis. Thrombi in the microcirculation impede blood flow. The zone of ischemia can spread if perfusion to the cord is not restored.

Rationale 3: Dilation of vessels would improve blood flow to the region and would not result in deterioration of neurological condition.

Rationale 4: This statement is not true.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 19-2

Question 8

Type: MCSA

A patient suffered an acute T6 spinal cord injury. Family has been told that the patient will likely be paraplegic. However, this morning the patient has limited use of his arms. How should the nurse explain this change?

1. There must be a second area of fracture higher in the spine.

2. The spinal cord is probably swollen above the area of original injury.

3. These changes are due to the low blood pressure he had before he got to the hospital.

4. This is a sign that he is dehydrated and will go away as we give him more IV fluids.

Correct Answer: 2

Rationale 1: It would be premature to suggest that a second area of injury exists.

Rationale 2: In a spinal cord injury, as the cord swells within the bony vertebrae, edema moves up and down the cord. A patient may exhibit symptoms as a result of the edema and not the initial injury. Because edema can extend the level of injury for several cord segments above and below the affected level, the extent of injury may not be determined for several days, until after the cord edema has resolved.

Rationale 3: There is no evidence that this change in neurological status is associated with prehospital hypotension.

Rationale 4: This change is not likely due to hypovolemia.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 19-2

Question 9

Type: MCSA

A patient is admitted with a fractured mandible and several fractured ribs. Which priority intervention would the nurse anticipate?

1. Providing pain medication

2. Determining lung function by chest x-ray

3. Maintaining spinal cord injury precautions

4. Stabilizing the rib fractures

Correct Answer: 3

Rationale 1: Provision of pain medication is indicated for this patient, but it is not the highest priority.

Rationale 2: It is important to determine the status of this patients lung function but this is not the intervention of highest priority.

Rationale 3: Since a spinal cord injury should be suspected in a patient with maxillofacial injury and clavicle or upper rib fractures, the patient should be maintained on spinal cord injury precautions until the injury has been ruled out.

Rationale 4: It is important to stabilize rib fractures, but this is not the intervention of highest priority.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 19-3

Question 10

Type: MCSA

It is suspected that a patient admitted with spinal cord injury has severe cord injury. The nurse would prepare the patient for which diagnostic test to determine the extent of this edema?

1. Angiography

2. Somatosensory-evoked potentials

3. CT scan

4. MRI

Correct Answer: 4

Rationale 1: Angiography is useful for patients with complex cervical spine fractures involving subluxation, extension into the foramen transversarium, or upper C1 to C3 fractures.

Rationale 2: Somatosensory-evoked potentials are used to establish a functional prognosis after resolution of spinal cord edema.

Rationale 3: CT scans are not the most sensitive tests for determination of cord edema.

Rationale 4: The MRI has greater sensitivity than a CT scan for diagnosing contusions, hematomas, and edema. The diagnostic test that would be the most helpful for this patient would be the MRI.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 19-3

Question 11

Type: MCSA

A patient is admitted with a spinal cord injury located at the 4th thoracic vertebral area. When assessing this patient, the nurse will expect to find sensory deficits at which anatomical area?

1. Anterior thigh

2. Nipple line

3. Umbilicus

4. Groin

Correct Answer: 2

Rationale 1: Innervation to the anterior thigh is at the 2nd lumbar vertebra.

Rationale 2: The nerve root for the 4th thoracic vertebra is approximately at the level of the nipple line.

Rationale 3: The nerve root for the umbilical region is the 10th thoracic vertebra.

Rationale 4: Innervation to the groin is at the 1st lumbar vertebra.

Global Rationale: 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 19-3

Question 12

Type: MCMA

A patient is diagnosed with a spinal cord injury located at the 1st and 2nd thoracic vertebra. The nurse will expect to find which deep tendon reflexes affected by this injury?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Supinator

2. Patellar

3. Triceps

4. Biceps

5. Achilles

Correct Answer: 2,5

Rationale 1: The supinator reflex originates at the 6th cervical vertebra, which is above the area injured.

Rationale 2: The patellar reflex originates at the 3rd lumbar vertebra. The patient has an injury at the 1st and 2nd thoracic vertebra, which means reflexes below this region will be affected.

Rationale 3: The triceps reflex originates at the 7th cervical vertebra, which is above the injured area.

Rationale 4: The biceps reflex originates at the 5th cervical vertebra which is above the injured area.

Rationale 5: The Achilles reflex originates at S1. The patient has an injury at the 1st and 2nd thoracic vertebra which means reflexes below this region will be affected.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 19-3

Question 13

Type: MCSA

A patient diagnosed with several fractured vertebra is having surgical stabilization. The nurse would reinforce which information about this surgery?

1. You will be required to wear a hard cervical collar for several months after the surgery.

2. After surgery you will be fitted for a halo device.

3. The fusion generally requires insertion of rods to stabilize your spine internally.

4. This is the first of a series of surgeries you will require.

Correct Answer: 3

Rationale 1: A hard cervical collar is a manual fixation device. Whether this device is required and how long it is required is variable and is likely not known prior to surgery.

Rationale 2: The patient may or may not require a halo device.

Rationale 3: Surgery is reserved for patients not sufficiently aligned with manual stabilization. Typically, spinal segments are fused, spinal canal is decompressed, and rods are inserted to stabilize thoracic spinal injuries.

Rationale 4: There is no indication that this patient will require a series of surgeries.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 19-4

Question 14

Type: MCMA

What interventions will the nurse include in the plan of care for a patient with a newly applied halo device and vest?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Assess motor and sensory function every shift.

2. Have the patient hold onto the halo struts during turns and repositioning.

3. Keep the pins and traction bars slightly loose to prevent pressure ulcers.

4. Tape a halo vest wrench to the front of the vest.

5. Use a moist cloth to clean the skin under the vest.

Correct Answer: 4,5

Rationale 1: Motor function and sensation should be assessed every 2 to 4 hours.

Rationale 2: Pulling on the struts can disrupt the device integrity and possible result in spinal cord damage. Having the patient hold onto the struts would likely cause stress to the device.

Rationale 3: The pins and traction bars should be firmly attached to provide stabilization.

Rationale 4: A halo vest wrench is to be taped to the front of the vest to be able to remove the vest in the event the patient needs to receive cardiopulmonary resuscitation.

Rationale 5: The vest is not removed for bathing, so a moist cloth is used to clean the skin under the vest.

Global Rationale: 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 19-4

Question 15

Type: MCSA

A patient recovering from surgery to stabilize a lumbar spinal cord injury is fitted with a clam shell brace. How would the nurse explain the purpose of this brace?

1. Wearing this brace will eliminate the need for further surgery.

2. You need to wear this device to support your surgical site.

3. This brace will maximize your range of motion.

4. You need to wear this brace to protect your surgical incision.

Correct Answer: 2

Rationale 1: It is premature to assure the patient that wearing a brace will eliminate need for further surgery.

Rationale 2: A clam shell brace after surgery to stabilize a lumbar spinal cord injury is prescribed to specifically support the surgical site.

Rationale 3: Stabilization devices do not necessarily maximize the patients range of motion but rather limit range of motion.

Rationale 4: The brace is not prescribed for the purpose of protecting the surgical incision.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 19-4

Question 16

Type: MCMA

A patient who injured his cervical spine was first taken to the emergency department of a small hospital where methylprednisolone (MPSS) was started intravenously. The patient has now been transferred to a neurointensive care unit in a large hospital. What interventions would the nurse in the receiving agency include in the plan of care?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Assess the patients breath sounds every 2 hours.

2. Check all stools for blood.

3. Keep the patient NPO.

4. Insert an indwelling urinary catheter so accurate intake and output can be measured.

5. Monitor for the development of hypotension.

Correct Answer: 1,2

Rationale 1: Steroid use is related to increased risk for pneumonia. The nurse should increase surveillance for changes in breath sounds.

Rationale 2: Use of steroids increases the patients risk for gastrointestinal bleeding. The nurse should check all stools, vomitus, or nasogastric drainage for the presence of blood.

Rationale 3: Use of steroids does not require the patient to be NPO.

Rationale 4: Use of steroids does not signify need for I&O measurement.

Rationale 5: Steroid use does not increase risk for hypotension.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 19-5

Question 17

Type: MCMA

A patient has a spinal cord injury at C6T1. During his bath the nurse notes piloerection. What nursing interventions are indicated?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Ask the patient about the presence of a headache.

2. Ignore the occurrence and continue with the bath.

3. Determine if the patients indwelling urinary catheter tubing is twisted.

4. Lower the head of the patients bed.

5. Cover the exposed portions of the patients body with a warm bath blanket.

Correct Answer: 1,3

Rationale 1: Piloerection and headache may be indicators of autonomic dysreflexia.

Rationale 2: Piloerection may indicate a serious complication and should not be ignored.

Rationale 3: Occlusion of the tubing from an indwelling urinary catheter may result in a full bladder, which is sufficient noxious stimulus to trigger a serious complication. Simply untwisting the tubing and allowing the bladder to drain may reverse this complication.

Rationale 4: The head of the bed should be raised.

Rationale 5: If this patient is experiencing a complication of spinal cord injury, piloerection is not related to cool environment.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 19-5

Question 18

Type: MCSA

A patient is admitted with a possible 2nd cervical vertebra injury. The nurse prepares for which most likely method to manage the patients respiratory system?

1. Incentive spirometer every hour while awake.

2. Quad coughing

3. Humidified oxygen via face mask

4. Intubation and mechanical ventilation

Correct Answer: 4

Rationale 1: Incentive spirometer is not the most likely method of managing this patients respiratory system.

Rationale 2: Quad coughing is not the most likely method for managing this patients respiratory system.

Rationale 3: Humidified oxygen via face mask will not be sufficient to manage this patients respiratory system.

Rationale 4: Patients with 1st or 2nd cervical injuries will require mechanical ventilation because of loss of phrenic nerve enervation to the diaphragm.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 19-5

Question 19

Type: MCSA

A patient in the intensive care unit with a spinal cord injury is receiving intravenous fluid therapy for hypotension. Which finding would the nurse evaluate as indicating the therapy has had its desired effect?

1. Normal temperature

2. Systolic blood pressure of 85 mm Hg

3. Systolic blood pressure of 120 mm Hg

4. Mean arterial pressure of 88 Hg

Correct Answer: 4

Rationale 1: Temperature is not a good way to assess for therapeutic effect in this intervention.

Rationale 2:

Rationale 3: Systolic pressure of 120 mm Hg may be difficult to obtain without administering so much fluid that the patient develops pulmonary edema.

Rationale 4: Judicious use of intravenous fluids is required when treating hypotension because too much fluid can precipitate pulmonary edema. However, medications might be needed to maintain adequate cardiac output and tissue perfusion. Current guidelines recommend that the mean arterial pressure be maintained 85 to 90 mm Hg for the first 7 days postspinal cord injury.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 19-5

Question 20

Type: MCMA

The nurse is helping a patient who is recovering from a 2nd to 4th thoracic vertebral injury with transferring from bed to sitting in a chair. Which nursing interventions are indicated to prevent the onset of orthostatic hypotension?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Apply a binder around the patients abdomen.

2. Be certain the patient is wearing compression stockings.

3. Swing the patients legs to the side of the bed in one swift, smooth movement.

4. Gradually raise the head of the bed.

5. Allow the patient to sit on the side of the bed with feet dangling before moving to a chair.

Correct Answer: 1,2,4,5

Rationale 1: The patient should be wearing an abdominal binder when moving from a lying to a sitting position.

Rationale 2: The patient should be wearing compression hose prior to moving from a lying to a sitting position.

Rationale 3: The patient will likely not tolerate a rapid movement to a sitting position as is indicated by this action.

Rationale 4: Chronic peripheral vasodilation causes orthostatic hypotension, particularly for patients with injuries at T6 or above. Chronic vasodilation in combination with a quick position change results in a loss of consciousness. Therefore, initial attempts to mobilize the patient are done slowly. Gradually raising the head of bed is indicated.

Rationale 5: Allowing the patient to side on the side of the bed with feet dangling until the blood pressure accommodates a sitting position will help prevent orthostatic hypotension.

Global Rationale: 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 19-5

Wagner, High Acuity Nursing, 6/E Test Bank

Copyright 2014 by Pearson Education, Inc.

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