Chapter 24 My Nursing Test Banks

Osborn, Medical-Surgical Nursing, 2e
Chapter 24

Question 1

Type: MCSA

The nurse would prioritize which nursing diagnosis when caring for a patient diagnosed with a spinal cord injury?

1. Fluid Volume Deficit

2. Impaired Physical Mobility

3. Ineffective Breathing Pattern

4. Altered Tissue Perfusion

Correct Answer: 3

Rationale 1: Fluid Volume Deficit is the nurses second priority, as it deals with circulation.

Rationale 2: Impaired Physical Mobility is an appropriate nursing diagnosis but is not the priority.

Rationale 3: The priority nursing diagnosis is Ineffective Breathing Pattern. Spinal cord injury can result in interruption of the nerves controlling breathing muscles.

Rationale 4: Altered Tissue Perfusion is a high-priority nursing diagnosis for this patient but does not hold the highest priority.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 24-4

Question 2

Type: MCSA

A patient with a spinal cord injury at the T1 level complains of a severe headache and an anxious feeling. Which is the most appropriate initial reaction by the nurse?

1. Try to calm the patient and make the environment soothing.

2. Assess for a full bladder.

3. Notify the health care provider.

4. Prepare the patient for diagnostic radiography.

Correct Answer: 2

Rationale 1: A calm, soothing environment is fine, but not what the patient needs in this case.

Rationale 2: Autonomic dysreflexia occurs in patients with injury at level T6 or higher. It is a life-threatening condition that requires immediate intervention. The most common cause is an overextended bladder or bowel. Symptoms include hypertension, headache, diaphoresis, bradycardia, visual changes, anxiety, and nausea.

Rationale 3: The nurse must perform an assessment first, then communicate the findings to the health care provider.

Rationale 4: This would not be an initial response for this patient.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 24-5

Question 3

Type: MCSA

The school nurse is called after a student falls down a flight of stairs. The student is breathing but unconscious. After calling the ambulance, which is the most appropriate action by the nurse?

1. Tilt the childs head back to help maintain an airway.

2. Place the child on the side to prevent aspiration.

3. Immobilize the neck, securing the head.

4. Try to rouse the child by gently shaking the shoulders.

Correct Answer: 3

Rationale 1: Guidelines for emergency care are avoiding flexing, extending, or rotating the neck. The child is breathing, so the nurse should monitor the airway but should not move the childs head.

Rationale 2: If the child vomits, the nurse should utilize the log-roll technique to turn the child while keeping the head, neck, and spine in alignment.

Rationale 3: Guidelines for emergency care are avoiding flexing, extending, or rotating the neck; immobilizing of the neck; securing the head; maintaining the patient in the supine position; and transferring from the stretcher with a backboard in place to the hospital bed. This patient is unconscious, and the nurse must protect the neck from any (or any further) damage.

Rationale 4: Rousing the child by shaking could cause damage to the spinal cord.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 24-1

Question 4

Type: FIB

The health care provider orders 2.5 mg IV of morphine sulfate (Morphine) to be administered to a patient with a ruptured intervertebral disc. The nurse has a 1 milliliter (mL) vial containing 10 mg of morphine sulfate. The nurse needs to withdraw ______ mL of morphine sulfate from the vial.

Standard Text:

Correct Answer: 0.25

Rationale : 10 mg/1 mL = 25 mg/x mL
x = 0.25 mL

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 24-4

Question 5

Type: FIB

The health care provider orders 15 mg IV of ketorolac (Toradol) for a patient who has recently undergone a spinal fusion. The nurse has a 5 milliliter (mL) ampule containing 60 mg of ketorolac. The nurse withdraws ______ mL of ketorolac from the ampule.

Standard Text:

Correct Answer: 1.25

Rationale : 60 mg/ 5 mL = 15 mg / x mL
x = 1.25 mL

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 24-4

Question 6

Type: MCSA

A hospitalized patient with a C7 cord injury asks, Why cant I feel my legs anymore? Which is the most appropriate action by the nurse?

1. Remind the patient of her injury and try to comfort her.

2. Call the health care provider and get an order for radiologic evaluation.

3. Prepare the patient for surgery, as her condition is worsening.

4. Explain to the patient that this could be a common, temporary problem.

Correct Answer: 4

Rationale 1: This action will be necessary but is not the most complete strategy.

Rationale 2: There is no indication that a radiologic evaluation is necessary.

Rationale 3: Surgery is not indicated at this point, as loss of sensation below the injury may occur.

Rationale 4: Spinal shock is a condition that affects almost half the people with acute spinal injury. It is characterized by a temporary loss of reflex function below the level of injury and includes the following symptomatology: flaccid paralysis of skeletal muscles, loss of sensation below the injury, and possibly bowel and bladder dysfunction and loss of ability to perspire below the injury level.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 24-3

Question 7

Type: SEQ

The nurse witnesses a motor vehicle accident (MVA) while off duty. Upon approaching the scene, the nurse observes a victim lying on the ground after being ejected from the vehicle. Beginning with the action the nurse must first take, place the actions in the correct order. All options must be used.

Standard Text: Click and drag the options below to move them up or down.

Choice 1. Check the victims breathing.

Choice 2. Check the victims pulse.

Choice 3. Check the victims airway.

Choice 4. Immobilize the victims spine.

Choice 5. Check for responsiveness.

Correct Answer: 5,4,3,1,2

Rationale 1: After immobilization, the nurse assesses the patients ABCs: airway, breathing, and circulation (pulse).

Rationale 2: After immobilization, the nurse assesses the patients ABCs: airway, breathing, and circulation (pulse).

Rationale 3: After immobilization, the nurse assesses the patients ABCs: airway, breathing, and circulation (pulse).

Rationale 4: The nurse immobilizes the spine using the jaw-thrust technique to prevent further injury to the spine.

Rationale 5: In an emergency situation, the nurse first assesses the patients level of consciousness during the primary survey of CPR.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 24-4

Question 8

Type: MCSA

The nurse is educating a patient and the family about different types of stabilization devices. Which statement by the patient indicates that the patient understands the benefit of using a halo fixation device instead of Gardner-Wells tongs?

1. I will have less pain if I use the halo device.

2. The halo device will allow me to get out of bed.

3. I am less likely to get an infection with the halo device.

4. The halo device does not have to stay in place as long.

Correct Answer: 2

Rationale 1: The patients pain level is not affected by the type of stabilization device used.

Rationale 2: A halo device does not require weights as the tongs do, thereby allowing the patient to be mobile.

Rationale 3: The patient does not have a greater risk of infection with the Gardner-Wells tongs; both devices require pins inserted into the skull.

Rationale 4: The time required for stabilization is not dependent on the type of stabilization device used.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 24-4

Question 9

Type: MCSA

A patient with a spinal cord injury was given IV Decadron (dexamethasone) after arriving in the emergency department. The patient also has a history of hypoglycemia. During the hospital stay, the nurse would expect to see which response to this medication?

1. Increased episodes of hypoglycemia

2. Possible episodes of hyperglycemia

3. No change in the patients glycemic parameters

4. Both hyper- and hypoglycemic episodes

Correct Answer: 2

Rationale 1: Another side effect is more common than hypoglycemia.

Rationale 2: A common side effect of corticosteroids is hyperglycemia. Stress as well as the medication could cause periods of elevated blood sugars.

Rationale 3: Corticosteroids commonly have an effect on serum glucose.

Rationale 4: Corticosteroids do not both increase and decrease serum glucose.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 24-4

Question 10

Type: MCSA

Which nursing action is appropriate for turning a patient who sustained a spinal cord injury?

1. This patient should not be turned.

2. Place pillows under the patients side for support turning the turn.

3. Have the patient grasp the side rail to turn.

4. Logroll the patient.

Correct Answer: 4

Rationale 1: The patient must be turned in order to avoid skin breakdown.

Rationale 2: Pillows are soft and will not provide the needed support to prevent twisting the spine.

Rationale 3: Grasping the side rail will twist the spine, which must be avoided.

Rationale 4: Logrolling is part of standard spinal precautions.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 24-4

Question 11

Type: MCSA

Which patient is at highest risk for a spinal cord injury?

1. 18-year-old male with a prior arrest for driving while intoxicated (DWI)

2. 20-year-old female with a history of substance abuse

3. 50-year-old female with osteoporosis

4. 35-year-old male who coaches a soccer team

Correct Answer: 1

Rationale 1: The three major risk factors for spinal cord injuries (SCI) are age (young adults), gender (higher incidence in males), and alcohol or drug abuse.

Rationale 2: Females tend to engage in less risk-taking behavior than young men.

Rationale 3: This woman does not have a higher risk of spinal cord injury.

Rationale 4: This man is not at increased risk of spinal cord injury.

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 24-1

Question 12

Type: MCSA

How should the nurse explain to a patient with a spinal cord injury why the extent of injury cannot be determined for several days to a week?

1. Tissue repair does not begin for 72 hours.

2. We have to wait until spinal shock resolves.

3. Neurons need time to regenerate, so it is hard to predict how you will progress.

4. The most serious changes after an injury take days to develop.

Correct Answer: 2

Rationale 1: The inability to determine the extent of injury is not related to delayed tissue repair.

Rationale 2: Spinal shock is a state of areflexia that occurs as a result of primary injury. It is not possible to determine the extent of injury until this condition abates.

Rationale 3: Neurons do not regenerate.

Rationale 4: Within 24 hours of the injury, necrosis of both gray and white matter begins if ischemia has been prolonged and the function of nerves passing through the injured area is lost.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 24-2

Question 13

Type: MCSA

A patient with a spinal cord injury is recovering from spinal shock. The nurse realizes that the patient should not develop a full bladder because what emergency condition can occur if it is not corrected quickly?

1. Autonomic dysreflexia

2. Autonomic crisis

3. Autonomic shutdown

4. Autonomic failure

Correct Answer: 1

Rationale 1: The nurse caring for spinal cord injury (SCI) patients should be attuned to the prevention of a distended bladder to prevent the chain of events that leads to autonomic dysreflexia.

Rationale 2: Autonomic crisis is not the term used to describe common complications of spinal injury associated with bladder distension.

Rationale 3: Autonomic shutdown is not the term used to describe common complications of spinal injury associated with bladder distension.

Rationale 4: Autonomic failure is not the term used to describe common complications of spinal injury associated with bladder distension.

Global Rationale:

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub: Safety and Infection Control

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 24-5

Question 14

Type: MCSA

The nurse suspects that a patient with spinal cord injury (SCI) is experiencing autonomic dysreflexia. The nurse elevates the head of the bed and removes the patients compression stockings while searching for the cause of this response. Performing these interventions helps to avoid which very dangerous complication of autonomic dysreflexia?

1. Hypoxia

2. Bradycardia

3. Elevated blood pressure

4. Tachycardia

Correct Answer: 3

Rationale 1: Hypoxia is not the most dangerous complication of autonomic dysreflexia.

Rationale 2: Bradycardia may occur but is not the most immediately dangerous complication.

Rationale 3: Autonomic dysreflexia is an emergency that requires immediate assessment and intervention to prevent complications of extremely high blood pressure. Additional nursing assistance will be needed and a colleague needs to reach the physician stat.

Rationale 4: Tachycardia is not the most common complication.

Global Rationale:

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub: Safety and Infection Control

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 24-5

Question 15

Type: MCSA

A patient with a spinal cord injury (SCI) has complete paralysis of the upper extremities and the lower part of the body. The nurse should use which medical term to correctly describe this in documentation?

1. Hemiplegia

2. Paresthesia

3. Paraplegia

4. Tetraplegia

Correct Answer: 4

Rationale 1: Hemiplegia describes paralysis on one side of the body.

Rationale 2: Paresthesia does not involve paralysis.

Rationale 3: Paraplegia is paralysis of the lower body.

Rationale 4: Tetraplegia describes complete paralysis of the upper extremities and complete paralysis of the lower part of the body.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 24-1

Question 16

Type: MCSA

The patient is admitted with injuries that were sustained in a fall. During the nurses first assessment upon admission, the findings are: blood pressure 90/60 (as compared to 136/66 in the emergency department), flaccid paralysis on the right side, absent bowel sounds, zero urine output, and palpation of a distended bladder. These signs are most consistent with which condition?

1. Paraplegia

2. Neurogenic shock

3. High cervical injury

4. Temporary hypovolemia

Correct Answer: 2

Rationale 1: Paraplegia is paralysis of both lower extremities. This patient has paralysis on the right.

Rationale 2: Findings associated with neurogenic shock include hypotension, bradycardia, peripheral vasodilation, and decreased cardiac output.

Rationale 3: There is no mention of the lack of respiratory effort generally associated with high cervical injury.

Rationale 4: Because the patient is bradycardic, the cause of these findings is more likely to be neurogenic shock than hypovolemic shock.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 24-5

Question 17

Type: MCMA

A patient with a T5 spinal cord injury has manifestations of autonomic dysreflexia. Which assessments would indicate a possible cause for this condition?

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

Standard Text: Select all that apply.

1. Presence of a pressure ulcer

2. Kinked urinary catheter tubing

3. Respiratory congestion

4. Diarrhea

5. Fecal impaction

Correct Answer: 1,2,5

Rationale 1: The presence of noxious stimuli below the level of the SCI may result in autonomic dysreflexia. A pressure ulcer may cause this complication.

Rationale 2: Autonomic dysreflexia can be caused by kinked catheter tubing, which allows the bladder to become full and triggers massive vasoconstriction below the injury site, producing the manifestations of this process.

Rationale 3: The presence of noxious stimuli below the level of the injury triggers autonomic dysreflexia. Respiratory congestion is not likely to be the cause in this patient.

Rationale 4: Diarrhea is not a common trigger for this complication.

Rationale 5: Fecal impaction may provide the noxious stimulus that triggers autonomic dysreflexia.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 24-5

Question 18

Type: MCSA

The nurse is providing community education regarding spinal cord injuries to a group of young adults. Which information should the nurse include?

1. The most common cause of spinal cord injury in your age group is trauma from motor vehicle accidents or sports-related accidents.

2. Spinal tumors are the most common cause of all injuries to the spinal cord and are not dependent on age.

3. Young people have a poorer survival rate than do older people.

4. Nontraumatic causes of spinal cord injury such as infection or inflammation are more common in younger people.

Correct Answer: 1

Rationale 1: Young adults are most likely to suffer a SCI from trauma such as MVAs or sports-related accidents.

Rationale 2: Spinal tumors are not the cause of the majority of SCIs.

Rationale 3: Older patients with severe injury have the poorest survival rates.

Rationale 4: Nontraumatic causes are more common in those over age 40.

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 24-1

Question 19

Type: MCMA

The school nurse is teaching a session on ways to prevent spinal cord injuries to a group of middle-school students. Which health promotion information should the nurse include?

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

Standard Text: Select all that apply.

1. Wear a helmet while riding a bicycle or motorcycle.

2. Eat a well-balanced diet with sufficient calcium.

3. Wear sunglasses.

4. Do not dive into unfamiliar water.

5. Do not ride in a car with someone who has been drinking.

Correct Answer: 1,4,5

Rationale 1: A key to reducing injuries is to protect the head and neck. Wearing a helmet for these activities helps provide that protection.

Rationale 2: Eating a well-balanced diet with sufficient calcium is good health information, but it is not specific to preventing spinal cord injury.

Rationale 3: Sunglasses protect the eyes but are not considered primary protection against injury to the spine.

Rationale 4: Diving into unfamiliar water or into familiar water that is at an unfamiliar level may result in cervical spine injury.

Rationale 5: The combination of friends and alcohol can reduce the drivers judgment, causing a motor vehicle accident, which is a major cause of SCI.

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 24-1

Question 20

Type: MCMA

The nursing assessment confirms that the patient has experienced loss of voluntary motor and sensory function of both upper and lower extremities, as well as bowel and bladder control, due to a spinal cord injury (SCI). The nurse recognizes that which is true regarding this patient?

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

Standard Text: Select all that apply.

1. This patient has experienced an incomplete spinal injury.

2. The patient is likely to regain only limited motor control.

3. All deep tendon reflexes are affected.

4. The injury was likely a result of trauma to the C1 to C4 level of the spinal cord.

5. Tetraplegia is the term for the patients neurological deficiencies.

Correct Answer: 3,4,5

Rationale 1: A complete spinal cord injury indicates complete loss of voluntary motor and sensory functions below the level of injury.

Rationale 2: The damage to the spinal cord in this type of injury is irreversible.

Rationale 3: The patients injuries would result in deep tendon reflex involvement.

Rationale 4: The injury was likely a result of trauma to the C1 to C4 level of the spinal cord. An injury at this level exhibits all the identified symptoms.

Rationale 5: Injuries involving the cervical spinal cord result in tetraplegia, or loss of motor and sensory function involving both upper extremities, both lower extremities, bowel, and bladder.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 24-2

Question 21

Type: MCMA

The nurse is caring for a patient who has been diagnosed with an incomplete spinal cord injury (SCI) that has resulted in central cord syndrome. The nurse expects which findings related to 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. It is likely a result of a hyperextension injury to the cervical spine.

2. Function, if restored, will occur first in the hands.

3. Loss of function will be greatest in the lower extremities.

4. Prognosis for recovery is poor.

5. The patient may have preexisting degenerative bone changes.

Correct Answer: 1,5

Rationale 1: Central cord syndrome is usually caused by a hyperextension injury resulting in damage to the center of the spinal cord.

Rationale 2: The typical pattern of recovery from central cord syndrome is return of lower extremity function first, followed by return of bladder function. Hand intrinsic function is often the last to return.

Rationale 3: In central cord syndrome, there is greater loss of motor and sensory function in the upper extremities than in the lower extremities.

Rationale 4: The overall prognosis for recovery from central cord syndrome is generally favorable.

Rationale 5: Central cord syndrome is the most common incomplete SCI. This injury can occur at any age, but it is seen most frequently in older patients who have degenerative bony changes in the cervical spine resulting in narrowing of the overall diameter of the spinal canal.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 24-2

Question 22

Type: MCSA

A patient who has experienced an incomplete spinal cord injury (SCI) is most likely to experience which effects?

1. Only a mild motor deficiency

2. Restoration of sensory function first

3. Some neurotransmission of impulses

4. A good prognosis for recovery

Correct Answer: 3

Rationale 1: The extent of motor deficiency depends on which portions of the cord are undamaged.

Rationale 2: The degree and progression of sensory function return will depend on which sections of the cord are undamaged.

Rationale 3: Patients who have experienced an incomplete spinal cord injury will have some preservation of sensory and/or motor function below the level of injury. In these patients, there is sparing of some of the spinal cord tracts, which allows neurotransmission to occur.

Rationale 4: The extent of recovery depends on which sections of the cord are left undamaged.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 24-2

Question 23

Type: MCMA

A patient with an incomplete spinal cord injury is being transferred from intensive care to the neurological trauma unit. The nurse realizes that in order to minimize the patients risk of developing autonomic hyperreflexia, which interventions should be included in the patients care plan?

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

Standard Text: Select all that apply.

1. Monitoring skin temperature in lower extremities

2. Assessing for abdominal distention

3. Bladder scan postvoiding

4. Assessing pulse oximetry levels with vital signs

5. Strict output monitoring

Correct Answer: 2,3,5

Rationale 1: Monitoring lower-extremity skin temperature is appropriate for detecting deep vein thrombosis.

Rationale 2: Causes of autonomic hyperreflexia are impacted stool or constipation, so assessing for abdominal distention is appropriate.

Rationale 3: The nurse caring for spinal cord injury (SCI) patients should be attuned to the prevention of a distended bladder to prevent the chain of events that leads to autonomic hyperreflexia. Scanning the bladder postvoiding can detect residual urine retention.

Rationale 4: Pulse oximetry is effective in monitoring for a decline in oxygen saturation and may be the initial indicator of a pulmonary embolus.

Rationale 5: Tracking urinary output carefully can help detect residual urine retention.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 24-5

Question 24

Type: MCSA

A patient is admitted after a fall that has resulted in spinal shock. When asked by the family how long the paralysis is likely to last, the nurses response is based on which understanding?

1. Spinal shock usually results in temporary paralysis.

2. There will likely be some minor improvement in the degree of paralysis.

3. Spinal shock is irreversible and the paralysis is likely to be permanent.

4. The severity of the injuries cannot be determined until the spinal shock resolves.

Correct Answer: 4

Rationale 1: At this point it is not possible to determine whether the paralysis is temporary or permanent or will lessen.

Rationale 2: There is no assurance that the paralysis will lessen.

Rationale 3: The duration of spinal shock is quite variable, lasting as little as a few hours or as long as several weeks after injury. During this period, it is impossible to determine the extent of the SCI.

Rationale 4: Spinal shock is a state of areflexia in which there is a loss of all motor, sensory, and reflex activity at the level of the injury and below. It is not possible to determine the severity of the injury until spinal shock has abated.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 24-3

Question 25

Type: MCSA

A patient with a recent spinal cord injury is at risk for complications to the gastrointestinal system. Which nursing intervention is primarily directed at minimizing this risk?

1. Insertion of a nasogastric tube

2. Regular assessment of the patients bowel sounds

3. Administration of a lansoprazole (Prevacid)

4. Elevating the end of the bed to 35 degrees

Correct Answer: 1

Rationale 1: The gastrointestinal effects of spinal shock include gastroparesis, loss of intestinal peristalsis, and ileus. Placement of a nasogastric or oral gastric tube will be necessary in the acute phase of SCI for decompression of the stomach.

Rationale 2: Regular assessment of bowel sounds will help determine the presence or absence of peristalsis, but it is not effective in reducing risk.

Rationale 3: Prevacid is a proton pump inhibitor that is used in the treatment of GERD.

Rationale 4: Elevating the head of the bed will have little effect on the gastrointestinal system and may be contraindicated for other reasons.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 24-4

Question 26

Type: MCMA

The nurse has assessed a patient who was admitted for rehabilitation after a fall that resulted in hemiplegia. The patients care plan may require nursing diagnoses related to which concerns?


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

Standard Text: Select all that apply.

1. Sensory perception

2. Body image

3. Cognitive abilities

4. Role performance

5. Independence

Correct Answer: 1,2,4,5

Rationale 1: The patient will experience changes in sensory perception that should be addressed in the care plan.

Rationale 2: Patients who have experienced an SCI experience significant psychosocial impact. These patients are faced with changes related to change of body image.

Rationale 3: Injuries resulting in hemiplegia are not likely to change a patients cognitive abilities for the long term unless other serious complications also occurred.

Rationale 4: Patients who have experienced an SCI experience significant psychosocial impact. These patients are faced with changes related to previous personal and interpersonal roles.

Rationale 5: Patients who have experienced an SCI experience significant psychosocial impact. These patients are faced with changes related to loss of independence.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 24-6

Question 27

Type: MCSA

The nurse is preparing to discuss discharge planning with a patient who is hemiplegic as a result of a diving accident and with the patients wife, who will be his primary caregiver. Which statement by the nurse would specifically address the needs of the caregiving wife?

1. We will begin bowel and bladder training in 2 weeks.

2. You will experience some role changes in your relationship.

3. The vocational rehabilitation company will contact you next week to set up your schedule.

4. You should plan respite time away from your husband every week.

Correct Answer: 4

Rationale 1: Bowel and bladder training is very important and will be a significant change for both the patient and the wife, but this is not the most important option statement.

Rationale 2: These role changes have already begun, so this is not the best option.

Rationale 3: All of the rehab visits, home health nurse visits, physician office visits, etc. are very important, but this is not the most important option provided.

Rationale 4: This wife is at high risk for caregiver role strain. Respite is essential. It is important for the nurse to make this statement so both the husband and wife recognize its importance.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 24-6

Question 28

Type: MCSA

A female patient who sustained a spinal cord injury resulting in paraplegia asks the nurse if she will ever be able to have children. How should the nurse respond?

1. You should consider adoption if you want to have a family.

2. Sexual intercourse will not be pleasurable for you any longer.

3. Your rehabilitation specialist will talk to you about this concern.

4. It is possible for some women with spinal cord injuries to become pregnant and bear children.

Correct Answer: 4

Rationale 1: It is premature for the nurse to suggest adoption.

Rationale 2: The patient has asked about having children, not about sexual intercourse.

Rationale 3: Return to sexual activity is discussed in rehabilitation education, but the patient is asking questions now. The nurse should be prepared to address this concern.

Rationale 4: The nurse should provide valid information without promising that this particular patient will be able to bear children.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 24-6

Question 29

Type: MCMA

The nurse recognizes that the rehabilitation goal for a patient who has experienced a spinal cord injury (SCI) is to assist the patient in which activities?

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

Standard Text: Select all that apply.

1. Adapting to the realization of the patients limitations

2. Providing the emotional support required for this adjustment

3. Reaching the patients highest potential for independence

4. Managing the physical pain such injuries cause

5. Assimilating back into the patients home environment

Correct Answer: 1,3,5

Rationale 1: Rehabilitation for patients with SCI consists of a comprehensive program designed to help them adapt to the limitations imposed by their injury.

Rationale 2: Providing emotional support is not a goal for rehabilitation but a means for assisting the patient to achieve goals.

Rationale 3: Rehabilitation for patients with SCI consists of a comprehensive program designed to help them reach the highest level of independence possible.

Rationale 4: Managing pain is a way to help the patient meet the goals of rehabilitation. The goal statement would be to reach the desired level of pain control.

Rationale 5: Rehabilitation for patients with SCI consists of a comprehensive program designed to help them reintegrate into the home environment and community.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 24-6

Question 30

Type: MCSA

The nurse is assessing the psychosocial status of a patient who experienced a spinal cord injury. What would provide the best subjective evidence of the patients state of mind?

1. The nurse asks the patient to identify members of his support system.

2. The patient says, I would enjoy some fast food for lunch.

3. The nurse enters the room and finds the patient crying.

4. The patient tells the nurse he was once treated for depression.

Correct Answer: 1

Rationale 1: Assessment of a patients psychosocial state is best achieved by assessing the patients own perception of the presence of a support system.

Rationale 2: It is possible that asking for food that the patient would enjoy reflects a positive psychosocial state. However, there could be many reasons for this statement. It is not the best subjective assessment.

Rationale 3: Crying is an objective sign.

Rationale 4: A history of depression is not necessarily proof of current depression.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 24-3

Question 31

Type: MCMA

A patient with a spinal cord injury (SCI) has a nursing diagnosis of Risk for Ineffective Tissue Perfusion related to the effects of neurogenic shock. The nurse includes which intervention in the patients 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. Fit the patient for an abdominal binder and thigh-length compression stockings.

2. Monitor administration of atropine and other vasoactive agents as ordered or by protocol.

3. Administer anticoagulant medication as ordered.

4. Measure and record the diameter of the calf every shift.

5. Measure and record intake and output.

Correct Answer: 1,2,5

Rationale 1: Use of an abdominal binder and thigh-high compression stockings will help venous blood return and minimize blood pooling in the abdomen and lower extremities.

Rationale 2: Vasoactive agents will support blood pressure and heart rate, thereby having a positive effect on cardiac output.

Rationale 3: Anticoagulant medications will not reverse the cardiovascular effects of neurogenic shock.

Rationale 4: Measuring the diameter of the calves is an intervention associated with treatment of deep vein thrombosis.

Rationale 5: Measuring and recording intake and output will help assess fluid volume status. Dehydration reduces tissue perfusion.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 24-4

Question 32

Type: MCMA

Risk for Constipation related to impaired gastric motility is added to the nursing care plan of a patient with a new spinal cord injury (SCI). The nurse would plan which interventions to address this diagnosis?

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

Standard Text: Select all that apply.

1. Check each stool for occult blood.

2. Administer stool softener as prescribed.

3. Institute chemical stimulation to initiate bowel evacuation.

4. Place the patient in an adult incontinence garment.

5. Manage parenteral feedings as ordered.

Correct Answer: 2,3,5

Rationale 1: Testing stool for occult blood is directed toward monitoring for a bleeding gastric ulcer. This patient has a potential for gastric ulceration related to the stress of this critical injury.

Rationale 2: To minimize the risk of constipation in a patient with SCI, the nurse should institute a bowel regimen of stool softener to help establish a regular bowel elimination pattern.

Rationale 3: To minimize the risk of constipation in a patient with SCI, the nurse should institute a bowel regimen of chemical stimulation such as a suppository to establish a regular bowel elimination pattern. The patients bowel elimination pattern should be monitored closely to ensure adequate bowel evacuation.

Rationale 4: There is no indication that an incontinence garment is necessary.

Rationale 5: Early nutritional support is often achieved through parenteral feedings until enteral feedings are introduced and tolerated.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 24-4

Question 33

Type: MCSA

A patient was admitted after falling from the roof of a one-story building. Assessment reveals presence of a patellar reflex, but loss of sensation in part of both feet. The nurse would plan for which level of bowel and bladder function?

1. Bladder function only

2. Bowel function only

3. Intact bladder and bowel function

4. Loss of both bladder and bowel function

Correct Answer: 4

Rationale 1: This assessment indicates a lesion around L3 or L4. Bladder continence would be lost.

Rationale 2: This assessment indicates a lesion around L3 or L4. Bowel continence would be lost.

Rationale 3: This assessment indicates a lesion around L3 or L4. Bladder and bowel continence would be lost.

Rationale 4: This assessment indicates a lesion around L3 or L4. Bladder and bowel continence would be lost.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 24-5

Question 34

Type: MCSA

A patient sustained a C4 fracture in a diving accident. The patients wife says, Ill be so glad when he gets off the ventilator so that he can communicate with me. How should the nurse respond to this statement?

1. It may be a few weeks before he is strong enough to breathe on his own.

2. We dont know if he will be able to talk when we get him off the ventilator.

3. There are ways we can teach both of you to communicate that will not require his being off the ventilator.

4. We need to focus on his getting better, not on how he will communicate.

Correct Answer: 3

Rationale 1: Injuries at C4 or higher cause paralysis of the diaphragm. Mechanical ventilation is likely to be necessary for the rest of the patients life.

Rationale 2: This patients injury will probably necessitate mechanical ventilation for life.

Rationale 3: The patient will likely be on the ventilator for the rest of his life. There are communication methods that can be used while the patient is still on the ventilator.

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