Exam 60: Spinal Cord and Peripheral Nerve Problems

A 38-yr-old patient who has had a spinal cord injury returned home following a stay in a rehabilitation facility. The home care nurse notes the spouse is performing many of the activities that the patient had been managing unassisted during rehabilitation. The appropriate nursing action at this phase of rehabilitation is to

A patient with neurogenic shock after a spinal cord injury is to receive lactated Ringer's solution 400 mL over 20 minutes. When setting the IV pump to deliver the IV fluid,the nurse will set the rate at how many milliliters per hour?

Which assessment data for a patient who has Guillain-Barré syndrome will require the nurse's most immediate action?

A patient hospitalized with a new diagnosis of Guillain-Barré syndrome has numbness and weakness of both feet. The nurse will anticipate teaching the patient about

Which action will the nurse take when caring for a patient who develops tetanus from injectable substance use?

A construction worker arrives at an urgent care center with a deep puncture wound from a rusty nail. The patient reports having had a tetanus booster 6 years ago. The nurse will anticipate

A 20-yr-old patient who sustained a T2 spinal cord injury 10 days ago tells the nurse,"I want to be transferred to a hospital where the nurses know what they are doing." Which action by the nurse is appropriate?

Which nursing action has the highest priority for a patient who was admitted 16 hours earlier with a C5 spinal cord injury?

Which action will the nurse include in the plan of care for a patient who is experiencing pain from trigeminal neuralgia?

After change-of-shift report on the neurology unit,which patient will the nurse assess first?

A patient with Bell's palsy refuses to eat while others are present because of embarrassment about drooling. The best response by the nurse is to

Which of these nursing actions for a patient with Guillain-Barré syndrome is appropriate for the nurse to delegate to experienced unlicensed assistive personnel (UAP)?

Which action will the nurse include in the plan of care for a patient who has a cauda equina spinal cord injury?

Which patient assessment will help the nurse identify potential complications of trigeminal neuralgia?

A patient is admitted with possible botulism poisoning after eating home-canned green beans. Which intervention ordered by the health care provider will the nurse question?

A patient is hospitalized with new onset of Guillain-Barré syndrome. The most essential assessment for the nurse to complete is

A patient has an incomplete left spinal cord lesion at the level of T7,resulting in Brown-Séquard syndrome. Which nursing action should be included in the plan of care?

Before administering botulinum antitoxin to a patient in the emergency department,it is most important for the nurse to

A patient is being evaluated for a possible spinal cord tumor. Which finding by the nurse requires the most immediate action?

To prevent autonomic hyperreflexia,which nursing action will the home health nurse include in the plan of care for a patient who has paraplegia at the T4 level ?