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

Question 1

When the nurse is planning care for a hospitalized patient who is experiencing an acute episode of trigeminal neuralgia, an appropriate action to include is

A) teach facial and jaw relaxation techniques.
B) assess intake and output and dietary intake.
C) apply ice packs for no more than 20 minutes.
D) spend time at the bedside talking with the patient.

Answer 1

assess intake and output and dietary intake.

Question 2

During assessment of the patient with a recurrence of symptoms of trigeminal neuralgia, the nurse should

A) examine the mouth and teeth thoroughly.
B) have the patient clench and relax the jaw and eyes.
C) identify trigger zones by lightly touching the affected side.
D) gently palpate the face to compare skin temperature bilaterally.

Answer 2

examine the mouth and teeth thoroughly.

Question 3

A patient with a neck fracture at the C5 level is admitted to the intensive care unit (ICU) following initial treatment in the emergency room. During initial assessment of the patient, the nurse recognizes the presence of spinal shock on finding

A) hypotension, bradycardia, and warm extremities.
B) involuntary, spastic movements of the arms and legs.
C) the presence of hyperactive reflex activity below the level of the injury.
D) flaccid paralysis and lack of sensation below the level of the injury.

Answer 3

flaccid paralysis and lack of sensation below the level of the injury.

Question 4

A patient arrives at an urgent care center with a deep puncture wound after stepping on a nail that was embedded in some old lumber in a field. The patient reports having had a tetanus booster 7 years ago. The nurse will anticipate

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

Question 5

A patient with a T1 spinal cord injury is admitted to the intensive care unit (ICU). The nurse will teach the patient and family that

A) use of the shoulders will be preserved.
B) full function of the patient's arms will be retained.
C) total loss of respiratory function may occur temporarily.
D) elevations in heart rate are common with this type of injury.

Question 6

The nurse discusses long-range goals with a patient with a C6 spinal cord injury. An appropriate patient outcome is

A) transfers independently to a wheelchair.
B) drives a car with powered hand controls.
C) turns and repositions self independently when in bed.
D) pushes a manual wheelchair on flat, smooth surfaces.

Question 7

The health care provider orders administration of IV methylprednisolone (Solu-Medrol) for the first 24 hours to a patient who experienced a spinal cord injury at the T10 level 3 hours ago. When evaluating the effectiveness of the medication the nurse will assess

A) blood pressure and heart rate.
B) respiratory effort and O₂ saturation.
C) motor and sensory function of the legs.
D) bowel sounds and abdominal distension.

Question 8

A patient with a history of a T₂ spinal cord tells the nurse, "I feel awful today. My head is throbbing, and I feel sick to my stomach." Which action should the nurse take first?

A) Notify the patient's health care provider.
B) Check the blood pressure (BP).
C) Give the ordered antiemetic.
D) Assess for a fecal impaction.

Question 9

When assessing a patient with newly diagnosed trigeminal neuralgia, the nurse will ask the patient about

A) triggers that lead to facial pain.
B) visual problems caused by ptosis.
C) poor appetite caused by a loss of taste.
D) decreased sensation on the affected side.

Question 10

When caring for a patient who has Guillain-Barré syndrome, which assessment data obtained by the nurse will require the most immediate action?

A) The patient complains of severe tingling pain in the feet.
B) The patient has continuous drooling of saliva.
C) The patient's blood pressure (BP) is 106/50 mm Hg.
D) The patient's quadriceps and triceps reflexes are absent.

Question 11

As a result of a gunshot wound, a patient has an incomplete right 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 left leg pain
B) Assessment of the patient for left arm weakness
C) Positioning the patient's right leg when turning the patient
D) Teaching the patient to look at the left leg to verify its position

Question 12

A patient with trigeminal neuralgia has a glycerol rhizotomy. During a follow-up visit after the rhizotomy, the nurse will evaluate that the patient has had a successful outcome for the surgery if the patient

A) uses an eye shield at night to protect the cornea from injury.
B) develops and implements a daily routine of facial exercises.
C) is careful to chew foods on the unaffected side of the mouth.
D) talks about enjoying social activities with family and friends.

Question 13

A 24-year-old patient is hospitalized with the onset of Guillain-Barré syndrome. During this phase of the patient's illness, the most essential assessment for the nurse to carry out is

A) monitoring the cardiac rhythm continuously.
B) determining the level of consciousness q2hr.
C) evaluating sensation and strength of the extremities.
D) performing constant evaluation of respiratory function.

Question 14

A patient who has numbness and weakness of both feet is hospitalized with Guillain-Barré syndrome. The nurse will anticipate that collaborative interventions at this time will include

A) intubation and mechanical ventilation.
B) insertion of a nasogastric (NG) feeding tube.
C) administration of methylprednisolone (Solu-Medrol).
D) IV infusion of immunoglobulin (Sandoglobulin).

Question 15

When caring for a patient who had a C8 spinal cord injury 10 days ago and has a weak cough effort, bibasilar crackles, and decreased breath sounds, the initial intervention by the nurse should be to

A) administer oxygen at 7 to 9 L/min with a face mask.
B) place the hands on the epigastric area and push upward when the patient coughs.
C) encourage the patient to use an incentive spirometer every 2 hours during the day.
D) suction the patient's oral and pharyngeal airway.

Question 16

A patient with a paraplegia resulting from a T₁₀ spinal cord injury has a neurogenic reflex bladder. When the nurse develops a plan of care for this problem, which nursing action will be most appropriate?

A) Teaching the patient how to self-catheterize
B) Assisting the patient to the toilet q2-3hr
C) Use of the Credé method to empty the bladder
D) Catheterization for residual urine after voiding

Question 17

A patient admitted to the emergency department is diagnosed with botulism, and an order for botulinum antitoxin is received. Before administering the antitoxin, it is most important for the nurse to

A) obtain baseline vital signs.
B) administer an intradermal test dose.
C) ask the patient about a history of allergies.
D) document the presence of neurologic symptoms.

Question 18

When teaching patients who are at risk for Bell's palsy because of previous herpes simplex infection, which information should the nurse include?

A) "You should call the doctor if pain or herpes lesions occur near the ear."
B) "Treatment of herpes with antiviral agents will prevent development of Bell's palsy."
C) "Medications to treat Bell's palsy work only if started before paralysis onset."
D) "You may be able to prevent Bell's palsy by doing facial exercises regularly."

Question 19

A patient with Guillain-Barré syndrome asks the nurse what has caused the disease. In responding to the patient, the nurse explains that Guillain-Barré syndrome

A) results from an acute infection and inflammation of the peripheral nerves.
B) is due to an immune reaction that attacks the covering of the peripheral nerves.
C) is caused by destruction of the peripheral nerves after exposure to a viral infection.
D) results from degeneration of the peripheral nerve caused by viral attacks.

Question 20

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

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

Question 21

When caring for a patient who experienced a T₁ spinal cord transsection 2 days ago, which collaborative and nursing actions will the nurse include in the plan of care? (Select all that apply.)

A) Endotracheal suctioning
B) Continuous cardiac monitoring
C) Avoidance of cool room temperature
D) Nasogastric tube feeding
E) Retention catheter care
F) Administration of H₂ receptor blockers

Question 22

A 25-year-old patient has returned home following extensive rehabilitation for a C8 spinal cord injury. The home care nurse visits and notices that the patient's spouse and parents are performing many of the activities of daily living (ADLs) that the patient had been managing during rehabilitation. The most appropriate action by the nurse at this time is to

A) tell the family members that the patient can perform ADLs independently.
B) remind the patient about the importance of independence in daily activities.
C) recognize that it is important for the patient's family to be involved in the patient's care and support their activities.
D) develop a plan to increase the patient's independence in consultation with the with the patient, spouse, and parents.

Question 23

A patient who sustained a T1 spinal cord injury a week ago refuses to discuss the injury and becomes verbally abusive to the nurses and other staff. The patient demands to be transferred to another hospital, where "they know what they are doing." The best response by the nurse to the patient's behavior is to

A) ask for the patient's input into the plan for care.
B) clarify that abusive behavior will not be tolerated.
C) reassure the patient that the anger will pass and rehabilitation will then progress.
D) ignore the patient's anger and continue to perform needed assessments and care.

Question 24

When caring for a patient who was admitted 24 hours previously with a C5 spinal cord injury, which nursing action has the highest priority?

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

Question 25

Which of these nursing actions for a patient with Guillain-Barré syndrome is most appropriate for the nurse to delegate to an experienced nursing assistant?

A) Nasogastric tube feeding q4hr
B) Artificial tear administration q2hr
C) Assessment for bladder distension q2hr
D) Passive range of motion to extremities q8hr

Question 26

In which order will the nurse perform the following actions when caring for a patient with possible cervical spinal cord trauma who is admitted to the emergency department?

A) Administer O₂ using a non-rebreathing mask.
B) Monitor cardiac rhythm and blood pressure.
C) Immobilize the patient's head, neck, and spine.
D) Transfer the patient to radiology for spinal CT.

Question 27

A 26-year-old patient with a C8 spinal cord injury tells the nurse, "My wife and I have always had a very active sex life, and I am worried that she may leave me if I cannot function sexually." The most appropriate response by the nurse to the patient's comment is to

A) advise the patient to talk to his wife to determine how she feels about his sexual function.
B) tell the patient that sildenafil (Viagra) helps to decrease erectile dysfunction in patients with spinal cord injury.
C) inform the patient that most patients with upper motor neuron injuries have reflex erections.
D) suggest that the patient and his wife work with a nurse specially trained in sexual counseling.

Question 28

A patient with possible botulism poisoning is admitted for observation and administration of botulinum antitoxin. Which of the following health care provider orders should the nurse question?

A) Maintain NPO status.
B) Obtain lumbar puncture tray.
C) Give magnesium citrate 8 oz now.
D) Administer 1500-ml tapwater enema.

Question 29

The nurse is caring for a patient who is being evaluated for a possible metastatic spinal cord tumor. Which of these data obtained when assessing the patient requires most immediate action by the nurse?

A) The patient has new onset weakness of both legs.
B) The patient complains of chronic level 6 pain on a 10-point scale.
C) The patient starts to cry and says, "I feel hopeless."
D) The patient expresses anxiety about having surgery.