Deck 61: Nursing Management: Peripheral Nerve and Spinal Cord Problems

Question 1

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

A) Encourage oral fluids to 3 L/day
B) Document neurologic symptoms
C) Position patient lying on the side
D) Observe respiratory status closely

Answer 1

Encourage oral fluids to 3 L/day

Question 2

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

A) Cardiac monitoring for bradycardia
B) Assessment of respiratory rate and effort
C) Application of pneumatic compression devices to legs
D) Administration of methylprednisolone (Solu-Medrol) infusion

Answer 2

Assessment of respiratory rate and effort

Question 3

When the nurse is developing a rehabilitation plan for a 30-year-old patient with a C6 spinal cord injury,an appropriate goal is that the patient will be able to

A) drive a car with powered hand controls.
B) push a manual wheelchair on a flat surface.
C) turn and reposition independently when in bed.
D) transfer independently to and from a wheelchair.

Answer 3

push a manual wheelchair on a flat surface.

Question 4

Which action will the nurse include in the plan of care for a 62-year-old patient who is experiencing pain from trigeminal neuralgia?

A) Assess fluid and dietary intake.
B) Apply ice packs for 20 minutes.
C) Teach facial relaxation techniques.
D) Spend time talking with the patient.

Question 5

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

A) The patient's triceps reflexes are absent.
B) The patient is continuously drooling saliva.
C) The patient complains of severe pain in the feet.
D) The patient's blood pressure (BP) is 150/82 mm Hg.

Question 6

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?

A) Assessment of the patient for right arm weakness
B) Assessment of the patient for increased right leg pain
C) Positioning the patient's left leg when turning the patient
D) Teaching the patient to look at the right leg to verify its position

Question 7

The nurse will explain to the patient who has a T2 spinal cord transection injury that

A) use of the shoulders will be limited.
B) function of both arms should be retained.
C) total loss of respiratory function may occur.
D) tachycardia is common with this type of injury.

Question 8

A 27-year-old patient is hospitalized with new onset of Guillain-Barré syndrome.The most essential assessment for the nurse to carry out is

A) determining level of consciousness.
B) checking strength of the extremities.
C) observing respiratory rate and effort.
D) monitoring the cardiac rate and rhythm.

Question 9

A 68-year-old 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

A) intubation and mechanical ventilation.
B) administration of corticosteroid drugs.
C) insertion of a nasogastric (NG) feeding tube.
D) infusion of immunoglobulin (Sandoglobulin).

Question 10

The nurse is admitting a patient with a neck fracture at the C6 level to the intensive care unit.Which assessment finding(s)indicate(s)neurogenic shock?

A) Hyperactive reflex activity below the level of injury
B) Involuntary, spastic movements of the arms and legs
C) Hypotension, bradycardia, and warm, pink extremities
D) Lack of sensation or movement below the level of injury

Question 11

When evaluating outcomes of a glycerol rhizotomy for a patient with trigeminal neuralgia,the nurse will

A) assess whether the patient is doing daily facial exercises.
B) question whether the patient is using an eye shield at night.
C) ask the patient about social activities with family and friends.
D) remind the patient to chew on the unaffected side of the mouth.

Question 12

Which nursing action will the home health nurse include in the plan of care for a patient with paraplegia at the T₄ level in order to prevent autonomic dysreflexia?

A) Support selection of a high-protein diet.
B) Discuss options for sexuality and fertility.
C) Assist in planning a prescribed bowel program.
D) Use quad coughing to strengthen cough efforts.

Question 13

A patient with paraplegia resulting from a T9 spinal cord injury has a neurogenic reflexic bladder.Which action will the nurse include in the plan of care?

A) Teach the patient the Credé method.
B) Instruct the patient how to self-catheterize.
C) Catheterize for residual urine after voiding.
D) Assist the patient to the toilet every 2 hours.

Question 14

Which action should the nurse take when assessing a patient with trigeminal neuralgia?

A) Have the patient clench the jaws.
B) Inspect the oral mucosa and teeth.
C) Palpate the face to compare skin temperature bilaterally.
D) Identify trigger zones by lightly touching the affected side.

Question 15

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

A) IV infusion of tetanus immune globulin (TIG).
B) administration of the tetanus-diphtheria (Td) booster.
C) intradermal injection of an immune globulin test dose.
D) initiation of the tetanus-diphtheria immunization series.

Question 16

A 20-year-old patient who sustained a T2 spinal cord injury 10 days ago angrily 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 best?

A) Clarify that abusive language will not be tolerated.
B) Request that the patient provide input for the plan of care.
C) Perform care without responding to the patient's comments.
D) Reassure the patient about the competence of the nursing staff.

Question 17

A 32-year-old pregnant 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

A) respect the patient's feelings and arrange for privacy at mealtimes.
B) teach the patient to chew food on the unaffected side of the mouth.
C) offer the patient liquid nutritional supplements at frequent intervals.
D) discuss the patient's concerns with visitors who arrive at mealtimes.

Question 18

The nurse assessing a 54-year-old female patient with newly diagnosed trigeminal neuralgia will ask the patient about

A) visual problems caused by ptosis.
B) triggers leading to facial discomfort.
C) poor appetite caused by loss of taste.
D) weakness on the affected side of the face.

Question 19

A 38-year-old patient has returned home following rehabilitation for a spinal cord injury.The home care nurse notes that the spouse is performing many of the activities that the patient had been managing unassisted during rehabilitation.The most appropriate action by the nurse at this time is to

A) remind the patient about the importance of independence in daily activities.
B) tell the spouse to stop because the patient is able to perform activities independently.
C) develop a plan to increase the patient's independence in consultation with the patient and the spouse.
D) recognize that it is important for the spouse to be involved in the patient's care and encourage that participation.

Question 20

The nurse identifies a patient with type 1 diabetes and a history of herpes simplex infection as being at risk for Bell's palsy.Which information should the nurse include in teaching the patient?

A) "You may be able to prevent Bell's palsy by doing facial exercises regularly."
B) "Prophylactic treatment of herpes with antiviral agents prevents Bell's palsy."
C) "Medications to treat Bell's palsy work only if started before paralysis onset."
D) "Call the doctor if you experience pain or develop herpes lesions near the ear."

Question 21

A 39-year-old patient is being evaluated for a possible spinal cord tumor.Which finding by the nurse requires the most immediate action?

A) The patient has new onset weakness of both legs.
B) The patient complains of chronic severe back pain.
C) The patient starts to cry and says, "I feel hopeless."
D) The patient expresses anxiety about having surgery.

Question 22

Which of these nursing actions for a 64-year-old patient with Guillain-Barré syndrome is most appropriate for the nurse to delegate to an experienced unlicensed assistive personnel (UAP)?

A) Nasogastric tube feeding q4hr
B) Artificial tear administration q2hr
C) Assessment for bladder distention q2hr
D) Passive range of motion to extremities q4hr

Question 23

A patient who had a C7 spinal cord injury a week ago has a weak cough effort and audible rhonchi.The initial intervention by the nurse should be to

A) administer humidified oxygen by mask.
B) suction the patient's mouth and nasopharynx.
C) push upward on the epigastric area as the patient coughs.
D) encourage incentive spirometry every 2 hours during the day.

Question 24

Following a cauda equina spinal cord injury,which action will the nurse include in the plan of care?

A) Catheterize patient every 3 to 4 hours.
B) Assist patient to ambulate several times daily.
C) Administer medications to reduce bladder spasm.
D) Stabilize the neck when repositioning the patient.

Question 25

A patient with neurogenic shock following a spinal cord injury is to receive lactated Ringer's solution 500 mL over 30 minutes.When setting the IV pump to deliver the IV fluid,the nurse will set the rate at how many mL/hour?

Question 26

A nurse who works on the neurology unit just received change-of-shift report.Which patient will the nurse assess first?

A) Patient with botulism who is experiencing difficulty swallowing
B) Patient with Bell's palsy who has herpes vesicles in front of the ear
C) Patient with neurosyphilis who has tabes dorsalis and decreased deep tendon reflexes
D) Patient with an abscess caused by injectable drug use who needs tetanus immune globulin

Question 27

Which finding in a patient with a spinal cord tumor is most important for the nurse to report to the health care provider?

A) Back pain that increases with coughing
B) Depression about the diagnosis of a tumor
C) Decreasing sensation and ability to move the legs
D) Anxiety about scheduled surgery to remove the tumor

Question 28

In which order will the nurse perform the following actions when caring for a patient with possible C5 spinal cord trauma who is admitted to the emergency department? (Put a comma and a space between each answer choice [A,B,C,D,E].)

A) Infuse normal saline at 150 mL/hr.
B) Monitor cardiac rhythm and blood pressure.
C) Administer O₂ using a non-rebreather mask.
D) Immobilize the patient's head, neck, and spine.
E) Transfer the patient to radiology for spinal computed tomography (CT).

Question 29

When caring for a patient who experienced a T2 spinal cord transection 24 hours ago,which collaborative and nursing actions will the nurse include in the plan of care ?

A) Urinary catheter care
B) Nasogastric (NG) tube feeding
C) Continuous cardiac monitoring
D) Maintain a warm room temperature
E) Administration of H₂ receptor blockers

Question 30

Which action will the nurse take when caring for a 46-year-old patient who develops tetanus from an injectable substance use?

A) Avoid use of sedatives.
B) Provide a quiet environment.
C) Check pupil reaction to light every 4 hours.
D) Provide range-of-motion exercises several times daily.

Question 31

A patient admitted with dermal ulcers who has a history of a T₃ spinal cord injury tells the nurse,"I have a pounding headache and I feel sick to my stomach." Which action should the nurse take first?

A) Check for a fecal impaction.
B) Give the prescribed analgesic.
C) Assess the blood pressure (BP).
D) Notify the health care provider.

Question 32

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

A) obtain the patient's temperature.
B) administer an intradermal test dose.
C) document the neurologic symptoms.
D) ask the patient about an allergy to eggs.

Question 33

A 33-year-old patient with a T? spinal cord injury asks the nurse whether he will be able to be sexually active.Which initial response by the nurse is best?

A) Reflex erections frequently occur, but orgasm may not be possible.
B) Sildenafil (Viagra) is used by many patients with spinal cord injury.
C) Multiple options are available to maintain sexuality after spinal cord injury.
D) Penile injection, prostheses, or vacuum suction devices are possible options.