Question 1

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

Accepted Answer

A)  remind the patient about the importance of independence in daily activities.
B)  tell the spouse to stop helping 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 participation. C

Question 2

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?

Accepted Answer

1200
To administer 400 mL in 20 minutes,the nurse will need to set the pump to run at 1200 mL/hour.

Question 3

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

Accepted Answer

A)  The patient's sacral area skin is reddened.
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. B

Question 4

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

Accepted Answer

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

Question 5

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

Accepted Answer

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

Question 6

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

Accepted Answer

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 7

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?

Accepted Answer

A)  Respond 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 8

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

Accepted Answer

A)  Cardiac monitoring for bradycardia
B)  Assessment of respiratory rate and effort
C)  Administration of low-molecular-weight heparin
D)  Application of pneumatic compression devices to legs

Question 9

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

Accepted Answer

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 10

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

Accepted Answer

A)  Patient with Bell's palsy who has herpes vesicles in front of the ear
B)  Patient with botulism who is drooling and experiencing difficulty swallowing
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 11

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

Accepted Answer

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 12

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)?

Accepted Answer

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 13

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

Accepted Answer

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

Question 14

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

Accepted Answer

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 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?

Accepted Answer

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

Question 16

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

Accepted Answer

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 17

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?

Accepted Answer

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 18

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

Accepted Answer

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 19

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

Accepted Answer

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 20

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 ?

Accepted Answer

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.

Exam 60: Spinal Cord and Peripheral Nerve Problems