Chapter 36Dysfunction of the Spinal Cord and Peripheral Nervous System: Nursing Management My Nursing Test Banks

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

MULTIPLE CHOICE

1.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?

1.

Adolescent female who plays golf

2.

Adolescent male who rides horses

3.

Thirty-year-old female housewife

4.

Fifty-year-old male who is a computer technician

ANS: 2

Most spinal cord injuries are caused by motor vehicle accidents; however, falls from horses and bicycles are common causes of these types of injuries. The average age of spinal cord injuries has risen to 40.2 in 2009. The adolescent female who plays golf is at a lower risk of sustaining a spinal cord injury than the adolescent male who rides horses. The 30-year-old female housewife and 50-year-old male computer technician are also at lower risk for experiencing this type of injury.

PTS: 1 DIF: Apply REF: Spinal Cord Injury: Epidemiology

2.A client being treated for a spinal cord injury needs immediate ventilatory support. The nurse realizes that this clients level of injury is most likely:

1.

C3.

2.

C6.

3.

T3.

4.

L3.

ANS: 1

High cervical injuries above C3 will result in loss of respiratory function and death unless ventilator support is immediately provided. Spinal cord injuries at C6, T3, or L3 do not need immediate ventilatory support.

PTS: 1 DIF: Analyze REF: Spinal Cord Injuries: Level of Injury

3.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:

1.

coccygeal.

2.

lumbar.

3.

thoracic.

4.

cervical.

ANS: 4

Because of greater movement, the cervical area is the most unstable area of the spinal cord and is the most vulnerable area for injury. The thoracic, lumbar, and coccygeal regions of the spinal cord are more stable and less vulnerable areas for injury.

PTS: 1 DIF: Analyze REF: Spinal Cord Injuries: Level of Injury

4.The nurse is caring for a client with a spinal cord injury located at T5. Which of the following should be included in this clients plan of care?

1.

Use mechanical ventilation.

2.

Assess blood glucose level for onset of diabetes.

3.

Assist with removal of pulmonary secretions.

4.

Provide assistive devices for ambulation.

ANS: 3

Because of the interruption in chest muscle innervation with spinal cord injuries located at level T7 and above, patients often need assistance with removal of secretions and have difficulty with inspiration and expiration. Mechanical ventilation is not needed for a spinal cord injury at level T5. A spinal cord injury does not precipitate the onset of diabetes. A client with a spinal cord injury at level T5 will not be able to use an assistive device to ambulate.

PTS: 1 DIF: Apply REF: Acute Management of Spinal Cord Injuries

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:

1.

within 8 hours of injury.

2.

between 8 and 12 hours of injury.

3.

between 12 and 24 hours of injury.

4.

48 hours after the injury.

ANS: 1

Early treatment of spinal cord trauma with large doses of methylprednisolone have been shown to be extremely effective in the prevention of spinal cord damage after trauma occurs if administered within 8 hours of injury. Providing this medication after 8 hours following an injury is less effective in the prevention of spinal cord damage after a traumatic event.

PTS: 1 DIF: Analyze REF: Spinal Cord Injuries: Evidence-Based Care

6.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?

1.

Administer pain medication.

2.

Position the client on the left side.

3.

Turn off the lights and decrease the noise in the room.

4.

Check the bladder for distension.

ANS: 4

The symptoms suggest autonomic hyperreflexia, a medical emergency. The client should be checked for a distended bladder and be prepared for catheterization. Pain medication, positioning, or reducing environmental stimuli will not treat the underlying cause of autonomic hyperreflexia.

PTS: 1 DIF: Apply REF: Emergency Management of Complications of SCIs

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

1.

L5

2.

T12

3.

S1

4.

T4

ANS: 4

Clients with spinal cord injuries above the level of T6 are at the greatest risk for complications associated with autonomic dysreflexia. This complication is not common with injuries at L5, T12, or S1.

PTS: 1 DIF: Apply REF: Emergency Management of Complications of SCIs

8.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?

1.

Blood pressure 80/55 mmHg

2.

Heart rate 48 beats per minute

3.

Reflexive emptying of the bladder

4.

Body temperature 97F

ANS: 3

Resolution of spinal shock is indicated by return of reflexes, replacement of flaccidity with hyperreflexes, and reflexive emptying of the bladder. Low blood pressure, low heart rate, and low body temperature are all indications of neurogenic shock, which is an aspect of spinal shock.

PTS: 1 DIF: Analyze REF: Emergency Management of Complications of SCIs

9.A client is recovering from a spinal cord injury at level T12. Once spinal shock has resolved and the clients status has stabilized, the client will need which of the following types of care going forward?

1.

Medical

2.

Nursing

3.

Physical therapy

4.

Spiritual

ANS: 2

Spinal cord injuries create a very intensive nursing situation for clients. It is one of the few conditions in which the need for nursing care is generally much greater than the need for medical care after the acute phase of recovery. Medical care is, of course, needed more during the acute phase of recovering from the injury. Physical therapy is one aspect of care that the client will need going forward; however, it is not as intensive as the nursing care required. Spiritual care may be needed once the client realizes that the ability to walk or function without assistance will not occur.

PTS: 1 DIF: Analyze REF: Spinal Cord Injuries: Collaborative Management

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?

1.

Tylenol

2.

Vicodin

3.

Reglan

4.

Dexamethasone

ANS: 4

Irradiation and large doses of dexamethasone are the usual treatment for spinal cord tumors. This will result in reduction of edema and relief of pain. Tylenol, Vicodin, and Reglan may need to be prescribed for symptoms such as headache, pain, and nausea, but they are not considered the primary treatment for a spinal cord tumor.

PTS: 1 DIF: Analyze REF: Spinal Cord Tumors: Surgery

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

1.

In the hands and arms, progressing to the shoulders and head

2.

At the top of the spine, progressing to the brain

3.

In the legs, progressing up the body

4.

In the face, spreading over the entire facial muscles

ANS: 3

Guillain-Barr syndrome is characterized by a weakness that starts in the lower extremities and progresses up the body to the trunk and arms and finally to the cranial nerves. Signs and symptoms associated with this disorder do not begin in the hands and arms, at the top of the spine, or in the face.

PTS: 1 DIF: Analyze REF: Guillain-Barre Syndrome: Etiology

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

1.

Risk for injury

2.

Ineffective breathing pattern

3.

Risk for infection

4.

Pain

ANS: 2

Clients diagnosed with Guillain-Barr often develop respiratory difficulties because of muscle weakness and ineffective cough. Upon diagnosis of the disorder, the client with Guillain-Barr syndrome is most likely not at risk for injury, pain, or infection. Once the symptoms begin to resolve, the clients risk for injury, pain, or infection will increase.

PTS: 1 DIF: Apply REF: Guillain-Barre Syndrome: Nursing Diagnoses

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

1.

Perform active range-of-motion exercises to all extremities.

2.

Avoid extreme temperature variances in food and drink.

3.

Stay in bed with little movement.

4.

Drink eight glasses of water a day.

ANS: 2

Extreme temperatures in food and drink can trigger severe facial pain along the trigeminal nerve. This is what the nurse should instruct the client. Active range-of-motion exercises will not help control the symptoms of this disorder. Staying in bed with little movement or drinking eight glasses of water a day will also not control the symptoms of this disorder.

PTS:1DIF:Apply

REF: Trigeminal Neuralgia: Planning and Implementation

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

1.

Eyes tend to dry out because the eyelids do not close.

2.

Eyes become irritated because the eye does not make tears.

3.

Eyes trap dust because the eyelid does not open and the eye needs to be flushed.

4.

The eye drops should not be prescribed and the physician should be notified.

ANS: 1

In Bells palsy, the eyelids do not close, and eye drops are used to keep the eye lubricated. Eye drops are not used because the eye does not make tears. Eye drops are not used to flush the eye. Eye drops will be prescribed. The physician does not need to be notified.

PTS: 1 DIF: Apply REF: Bells Palsy: Planning and Implementation

MULTIPLE RESPONSE

1.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.)

1.

Increasing neurological impairment

2.

Paralysis

3.

Decubitus ulcers

4.

Peripheral vascular disease

5.

Loss of bowel and bladder function

6.

Osteoporosis

ANS: 1, 2, 5

Radiation complications will cause damage manifested as sensory impairments occurring after the completion of the radiation treatments. This can progress to increasing neurological impairment, paralysis, and loss of bowel and bladder function. Decubitus ulcers, peripheral vascular disease, and osteoporosis are not complications of radiation therapy for a spinal cord tumor.

PTS: 1 DIF: Apply REF: Spinal Cord Tumors: Radiation Therapy

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

1.

falls.

2.

motor vehicle crashes.

3.

sports injuries.

4.

gunshot wounds.

5.

walking.

6.

gardening.

ANS: 1, 2, 3, 4

Most spinal cord injuries are caused by motor vehicle accidents. Falls, gunshot wounds, and sports-related accidents also cause a significant number of these types of injuries. Spinal cord injuries are not caused by walking or gardening.

PTS: 1 DIF: Analyze REF: Spinal Cord Injury: Etiology

3.A client is diagnosed with Bells palsy. Which of the following will the nurse most likely assess in this client?

1.

Facial weakness

2.

Dry eye

3.

Drooling

4.

Impaired speech

5.

Dizziness

6.

Shortness of breath

ANS: 1, 2, 3, 4, 5

Symptoms of Bells palsy usually begin with facial weakness, pain, a dry eye, and dry mouth. Over time, additional symptoms include: facial twitching, hypersensitivity to sound, drooling, impaired sense of taste, impaired speech, dizziness, and the inability to blink or close the eye. Shortness of breath is not a symptom of Bells palsy.

PTS:1DIF:Apply

REF: Bells Palsy: Assessment with Clinical Manifestations

4.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.)

1.

Paresthesias

2.

Paralysis

3.

Hypotension

4.

Cardiac dysrhythmias

5.

Paresis

6.

Pain

ANS: 1, 2, 5, 6

Paresthesias, paralysis, paresis, and pain are common results of nerve injuries and the degree of dysfunction associated with each of these findings will vary and may change according to the injury. Hypotension and cardiac dysrhythmias are not common assessment findings with a peripheral nerve injury.

PTS:1DIF:Apply

REF: Peripheral Nerve Injuries: Assessment with Clinical Manifestations

5.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.)

1.

Electromyography

2.

Electroencephalogram

3.

Electrocardiogram

4.

Allens test

5.

Tinels sign

6.

Phalens sign

ANS: 1, 5, 6

Diagnosis of carpal tunnel syndrome is made through the use of electromyography, Tinels sign, and Phalens sign. Electroencephalogram, electrocardiogram, and the Allens test are not used to diagnosed carpal tunnel syndrome.

PTS: 1 DIF: Analyze REF: Carpal Tunnel Syndrome: Diagnostic Tests

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