Question 1

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

Accepted Answer

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. B

Question 2

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

Accepted Answer

A)   Assist with selection of a high protein diet.
B)   Use quad coughing to assist cough effort.
C)   Discuss options for sexuality and fertility.
D)   Teach the purpose of a prescribed bowel program. D

Question 3

In which order will the nurse perform the following actions when caring for a patient with possible C6 spinal cord trauma who is admitted to the emergency department? Put a comma and space between each solve choice (a, b, c, d, etc.) ____________________ A) Infuse normal saline at 150 mL/hr. B) Monitor cardiac rhythm and blood pressure. C) Administer O₂ using a non-rebreather mask. D) Transfer the patient to radiology for spinal computed tomography ( CT ). E) Immobilize the patient's head, neck, and spine.

Accepted Answer

E, C, B, A, D
The first action should be to prevent further injury by stabilizing the patient's spinal cord. Maintenance of oxygenation by administration of 100% O₂ is the second priority. Because neurogenic shock is a possible complication, monitoring of heart rhythm and BP are indicated, followed by infusing normal saline for volume replacement. A CT scan to determine the extent and level of injury is needed once initial assessment and stabilization are accomplished.

Question 4

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

Accepted Answer

A)   obtain the patient's temperature.
B)   administer an intradermal test dose.
C)   ask the patient about a history of egg allergies.
D)   document the presence of neurologic symptoms.

Question 5

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

Accepted Answer

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.

Question 6

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

Accepted Answer

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

Question 7

A 26-year-old patient with a T3 spinal cord injury asks the nurse about whether he will be able to be sexually active. Which initial response by the nurse is best?

Accepted Answer

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.

Question 8

A patient who sustained a spinal cord injury a week ago becomes angry, telling the nurse "I want to be transferred to a hospital where the nurses know what they are doing!" Which reaction by the nurse is best?

Accepted Answer

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 about the competence of the nursing staff.
D)   Continue to perform care without responding to the patient's comments.

Question 9

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

Accepted Answer

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

Question 10

When evaluating a patient with trigeminal neuralgia who has had a glycerol rhizotomy, the nurse will

Accepted Answer

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

Question 11

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?

Accepted Answer

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

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

Accepted Answer

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

Question 13

A patient who has numbness and weakness of both feet is hospitalized with Guillain-Barré syndrome. The nurse will anticipate the need to teach the patient about

Accepted Answer

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

Question 14

When caring for a patient who had a C8 spinal cord injury 10 days ago and has a weak cough effort and loose-sounding secretions, the initial intervention by the nurse should be to

Accepted Answer

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

Question 15

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

Accepted Answer

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

Question 16

A patient with paraplegia resulting from a T10 spinal cord injury has a neurogenic reflex bladder. Which action will the nurse include in the plan of care?

Accepted Answer

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

Question 17

To evaluate the effectiveness of IV methylprednisolone (Solu-Medrol) given to a patient with a T4 spinal cord injury, which information is most important for the nurse to obtain?

Accepted Answer

A)   Leg strength and sensation
B)   Skin temperature and color
C)   Blood pressure and apical heart rate
D)   Respiratory effort and O2 saturation

Question 18

The nurse is assessing a patient who 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 19

A patient with a history of a T2 spinal cord injury 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?

Accepted Answer

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

Question 20

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

Accepted Answer

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.

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