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

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Chapter 36--Dysfunction 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 . 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 client’s level of injury is most likely: 1. C3. 2. C6. 3. T3. 4. L3. 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. 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 client’s 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. 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. 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. 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 client’s spinal cord injury is at which of the following levels? 1. L5 2. T12 3. S1 4. T4 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 97°F 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 client’s 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 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 PTS: 1 DIF: Analyze REF: Spinal Cord Tumors: Surgery 11. 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? 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 PTS: 1 DIF: Analyze REF: Guillain-Barre Syndrome: Etiology 12. 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? 1. Risk for injury 2. Ineffective breathing pattern 3. Risk for infection 4. Pain 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. PTS: 1 DIF: Apply REF: Trigeminal Neuralgia: Planning and Implementation 14. 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? 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.” PTS: 1 DIF: Apply REF: Bell's 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 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. PTS: 1 DIF: Analyze REF: Spinal Cord Injury: Etiology 3. A client is diagnosed with Bell’s 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 PTS: 1 DIF: Apply REF: Bell's 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 PTS: 1 DIF: 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. Allen’s test 5. Tinel’s sign 6. Phalen’s sign PTS: 1 DIF: Analyze REF: Carpal Tunnel Syndrome: Diagnostic Tests [Show More]

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