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Chapter 43: Care of Patients with Problems of the CNS: The Spinal Cord
Terms in this set (30)
1. A nurse promotes the prevention of lower back pain by teaching clients at a community center. Which
instruction should the nurse include in this education?
a. Participate in an exercise program to strengthen muscles.
b. Purchase a mattress that allows you to adjust the firmness.
c. Wear flat instead of high-heeled shoes to work each day.
d. Keep your weight within 20% of your ideal body weight.
Exercise can strengthen back muscles, reducing the incidence of low back pain. The other options will not
prevent low back pain.
2. A nurse plans care for a client with lower back pain from a work-related injury. Which intervention should
the nurse include in this clients plan of care?
a. Encourage the client to stretch the back by reaching toward the toes.
b. Massage the affected area with ice twice a day.
c. Apply a heating pad for 20 minutes at least four times daily.
d. Advise the client to avoid warm baths or showers.
Heat increases blood flow to the affected area and promotes healing of injured nerves. Stretching and ice will
not promote healing, and there is no need to avoid warm baths or showers.
3. A nurse assesses a client who is recovering from a diskectomy 6 hours ago. Which assessment finding
should the nurse address first?
a. Sleepy but arouses to voice
b. Dry and cracked oral mucosa
c. Pain present in lower back
d. Bladder palpated above pubis
A distended bladder may indicate damage to the sacral spinal nerves. The other findings require the nurse to
provide care but are not the priority or a complication of the procedure.
4. A nurse assesses clients at a community center. Which client is at greatest risk for lower back pain?
a. A 24-year-old female who is 25 weeks pregnant
b. A 36-year-old male who uses ergonomic techniques
c. A 45-year-old male with osteoarthritis
d. A 53-year-old female who uses a walker
Osteoarthritis causes changes to support structures, increasing the clients risk for low back pain. The other
clients are not at high risk.
5. A nurse teaches a client who is recovering from a spinal fusion. Which statement should the nurse include in
this clients postoperative instructions?
a. Only lift items that are 10 pounds or less.
b. Wear your brace whenever you are out of bed.
c. You must remain in bed for 3 weeks after surgery.
d. You are prescribed medications to prevent rejection.
Clients who undergo spinal fusion are fitted with a brace that they must wear throughout the healing process
(usually 3 to 6 months) whenever they are out of bed. The client should not lift anything. The client does not
need to remain in bed. Medications for rejection prevention are not necessary for this procedure.
6. A nurse assesses a client who is recovering from anterior cervical diskectomy and fusion. Which
complication should alert the nurse to urgently communicate with the health care provider?
a. Auscultated stridor
b. Weak pedal pulses
c. Difficulty swallowing
d. Inability to shrug shoulders
Postoperative swelling can narrow the trachea, cause a partial airway obstruction, and manifest as stridor. The
client may also have trouble swallowing, but maintaining an airway takes priority. Weak pedal pulses and an
inability to shrug the shoulders are not complications of this surgery.
7. A nurse assesses a client with a spinal cord injury at level T5. The clients blood pressure is 184/95 mm Hg,
and the client presents with a flushed face and blurred vision. Which action should the nurse take first?
a. Initiate oxygen via a nasal cannula.
b. Place the client in a supine position.
c. Palpate the bladder for distention.
d. Administer a prescribed beta blocker.
The client is manifesting symptoms of autonomic dysreflexia. Common causes include bladder distention, tight
clothing, increased room temperature, and fecal impaction. If persistent, the client could experience neurologic
injury. Precipitating conditions should be eliminated and the physician notified. The other actions would not be
8. An emergency room nurse initiates care for a client with a cervical spinal cord injury who arrives via
emergency medical services. Which action should the nurse take first?
a. Assess level of consciousness.
b. Obtain vital signs.
c. Administer oxygen therapy.
d. Evaluate respiratory status.
The first priority for a client with a spinal cord injury is assessment of respiratory status and airway patency.
Clients with cervical spine injuries are particularly prone to respiratory compromise and may even require
intubation. The other assessments should be performed after airway and breathing are assessed.
9. An emergency department nurse cares for a client who experienced a spinal cord injury 1 hour ago. Which
prescribed medication should the nurse prepare to administer?
a. Intrathecal baclofen (Lioresal)
b. Methylprednisolone (Medrol)
c. Atropine sulfate
d. Epinephrine (Adrenalin)
Methylprednisolone (Medrol) should be given within 8 hours of the injury. Clients who receive this therapy
usually show improvement in motor and sensory function. The other medications are inappropriate for this
10. A nurse teaches a client with a lower motor neuron lesion who wants to achieve bladder control. Which
statement should the nurse include in this clients teaching?
a. Stroke the inner aspect of your thigh to initiate voiding.
b. Use a clean technique for intermittent catheterization.
c. Implement digital anal stimulation when your bladder is full.
d. Tighten your abdominal muscles to stimulate urine flow.
In clients with lower motor neuron problems such as spinal cord injury, performing a Valsalva maneuver or
tightening the abdominal muscles are interventions that can initiate voiding. Stroking the inner aspect of the
thigh may initiate voiding in a client who has an upper motor neuron problem. Intermittent catheterization and
digital anal stimulation do not initiate voiding or bladder control.
11. A nurse is caring for a client with paraplegia who is scheduled to participate in a rehabilitation program.
The client states, I do not understand the need for rehabilitation; the paralysis will not go away and it will not
get better. How should the nurse respond?
a. If you dont want to participate in the rehabilitation program, Ill let the provider know.
b. Rehabilitation programs have helped many clients with your injury. You should give it a chance.
c. The rehabilitation program will teach you how to maintain the functional ability you have and prevent
d. When new discoveries are made regarding paraplegia, people in rehabilitation programs will benefit first.
Participation in rehabilitation programs has many purposes, including prevention of disability, maintenance of
functional ability, and restoration of function. The other responses do not meet this clients needs.
12. After teaching a client with a spinal cord injury, the nurse assesses the clients understanding. Which client
statement indicates a correct understanding of how to prevent respiratory problems at home?
a. Ill use my incentive spirometer every 2 hours while Im awake.
b. Ill drink thinned fluids to prevent choking.
c. Ill take cough medicine to prevent excessive coughing.
d. Ill position myself on my right side so I dont aspirate.
Often, the person with a spinal cord injury will have weak intercostal muscles and is at higher risk for
developing atelectasis and stasis pneumonia. Using an incentive spirometer every 2 hours helps the client
expand the lungs more fully and prevents atelectasis. Clients should drink fluids that they can tolerate; usually
thick fluids are easier to tolerate. The client should be encouraged to cough and clear secretions. Clients should be placed in high-Fowlers position to prevent aspiration.
13. A nurse assesses a client with early-onset multiple sclerosis (MS). Which clinical manifestation should the
nurse expect to find?
a. Hyperresponsive reflexes
b. Excessive somnolence
d. Heat intolerance
Early signs and symptoms of MS include changes in motor skills, vision, and sensation. Hyperresponsive
reflexes, excessive somnolence, and heat intolerance are later manifestations of MS.
14. A nurse cares for a client who presents with an acute exacerbation of multiple sclerosis (MS). Which
prescribed medication should the nurse prepare to administer?
a. Baclofen (Lioresal)
b. Interferon beta-1b (Betaseron)
c. Dantrolene sodium (Dantrium)
d. Methylprednisolone (Medrol)
Methylprednisolone is the drug of choice for acute exacerbations of the disease. The other drugs are not used to treat acute exacerbations of MS. Interferon beta-1b is used to treat and control MS, decrease specific symptoms, and slow the progression of the disease. Baclofen and dantrolene sodium are prescribed to lessen muscle spasticity associated with MS.
15. A nurse assesses a client with multiple sclerosis after administering prescribed fingolimod (Gilenya). For
which adverse effect should the nurse monitor?
a. Peripheral edema
b. Black tarry stools
d. Nausea and vomiting
Fingolimod (Gilenya) is an antineoplastic agent that can cause bradycardia, especially within the first 6 hours
after administration. Peripheral edema, black and tarry stools, and nausea and vomiting are not adverse effects
16. A nurse is teaching a client with multiple sclerosis who is prescribed cyclophosphamide (Cytoxan) and
methylprednisolone (Medrol). Which statement should the nurse include in this clients discharge teaching?
a. Take warm baths to promote muscle relaxation.
b. Avoid crowds and people with colds.
c. Relying on a walker will weaken your gait.
d. Take prescribed medications when symptoms occur.
The client should be taught to avoid people with any type of upper respiratory illness because these
medications are immunosuppressive. Warm baths will exacerbate the clients symptoms. Assistive devices may
be required for safe ambulation. Medication should be taken at all times and should not be stopped.
17. A nurse assesses a client with a neurologic disorder. Which assessment finding should the nurse identify as
a late manifestation of amyotrophic lateral sclerosis (ALS)?
c. Muscle weakness
d. Impairment of respiratory muscles
In ALS, progressive muscle atrophy occurs until a flaccid quadriplegia develops. Eventually, the respiratory
muscles are involved, which leads to respiratory compromise. Dysarthria, dysphagia, and muscle weakness are
early clinical manifestations of ALS.
18. A nurse cares for several clients on a neurologic unit. Which prescription for a client should direct the
nurse to ensure that an informed consent has been obtained before the test or procedure?
a. Sensation measurement via the pinprick method
b. Computed tomography of the cranial vault
c. Lumbar puncture for cerebrospinal fluid sampling
d. Venipuncture for autoantibody analysis
A lumbar puncture is an invasive procedure with many potentially serious complications. The other
assessments or tests are considered noninvasive and do not require an informed consent
19. A nurse prepares a client for prescribed magnetic resonance imaging (MRI). Which action should the nurse
implement prior to the test?
a. Implement nothing by mouth (NPO) status for 8 hours.
b. Withhold all daily medications until after the examination.
c. Administer morphine sulfate to prevent claustrophobia during the test.
d. Place the client in a gown that has cloth ties instead of metal snaps.
Metal objects are a hazard because of the magnetic field used in the MRI procedure. Morphine sulfate is not
administered to prevent claustrophobia; lorazepam (Ativan) or diazepam (Valium) may be used instead. The
client does not need to be NPO, and daily medications do not need to be withheld prior to MRI.
20. A nurse cares for a client with a spinal cord injury. With which interdisciplinary team member should the
nurse consult to assist the client with activities of daily living?
a. Social worker
b. Physical therapist
c. Occupational therapist
d. Case manager
The occupational therapist instructs the client in the correct use of all adaptive equipment. In collaboration with
the therapist, the nurse instructs family members or the caregiver about transfer skills, feeding, bathing,
dressing, positioning, and skin care. The other team members are consulted to assist the client with unrelated
21. A nurse cares for a client with amyotrophic lateral sclerosis (ALS). The client states, I do not want to be
placed on a mechanical ventilator. How should the nurse respond?
a. You should discuss this with your family and health care provider.
b. Why are you afraid of being placed on a breathing machine?
c. Using the incentive spirometer each hour will delay the need for a ventilator.
d. What would you like to be done if you begin to have difficulty breathing?
ALS is an adult-onset upper and lower motor neuron disease characterized by progressive weakness, muscle
wasting, and spasticity, eventually leading to paralysis. Once muscles of breathing are involved, the client must
indicate in the advance directive what is to be done when breathing is no longer possible without intervention. The other statements do not address the clients needs
22. A nurse assesses the health history of a client who is prescribed ziconotide (Prialt) for chronic back pain.
Which assessment question should the nurse ask?
a. Are you taking a nonsteroidal anti-inflammatory drug?
b. Do you have a mental health disorder?
c. Are you able to swallow medications?
d. Do you smoke cigarettes or any illegal drugs?
Clients who have a mental health or behavioral health problem should not take ziconotide. The other questions
do not identify a contraindication for this medication.
1. A nurse assesses a client who recently experienced a traumatic spinal cord injury. Which assessment data
should the nurse obtain to assess the clients coping strategies? (Select all that apply.)
a. Spiritual beliefs
b. Level of pain
c. Family support
d. Level of independence
e. Annual income
f. Previous coping strategies
ANS: A, C, D, F
Information about the clients preinjury psychosocial status, usual methods of coping with illness, difficult
situations, and disappointments should be obtained. Determine the clients level of independence or dependence
and his or her comfort level in discussing feelings and emotions with family members or close friends. Clients
who are emotionally secure and have a positive self-image, a supportive family, and financial and job security
often adapt to their injury. Information about the clients spiritual and religious beliefs or cultural background
also assists the nurse in developing the plan of care. The other options do not supply as much information
2. After teaching a client with a spinal cord tumor, the nurse assesses the clients understanding. Which
statements by the client indicate a correct understanding of the teaching? (Select all that apply.)
a. Even though turning hurts, I will remind you to turn me every 2 hours.
b. Radiation therapy can shrink the tumor but also can cause more problems.
c. Surgery will be scheduled to remove the tumor and reverse my symptoms.
d. I put my affairs in order because this type of cancer is almost always fatal.
e. My family is moving my bedroom downstairs for when I am discharged home.
ANS: A, B, E
Although surgery may relieve symptoms by reducing pressure on the spine and debulking the tumor, some
motor and sensory deficits may remain. Spinal tumors usually cause disability but are not usually fatal.
Radiation therapy is often used to shrink spinal tumors but can cause progressive spinal cord degeneration and neurologic deficits. The client should be turned every 2 hours to prevent skin breakdown and arrangements should be made at home so that the client can complete activities of daily living without needing to go up and down stairs.
3. After teaching a male client with a spinal cord injury at the T4 level, the nurse assesses the clients
understanding. Which client statements indicate a correct understanding of the teaching related to sexual
effects of this injury? (Select all that apply.)
a. I will explore other ways besides intercourse to please my partner.
b. I will not be able to have an erection because of my injury.
c. Ejaculation may not be as predictable as before.
d. I may urinate with ejaculation but this will not cause infection.
e. I should be able to have an erection with stimulation.
ANS: C, D, E
Men with injuries above T6 often are able to have erections by stimulating reflex activity. For example,
stroking the penis will cause an erection. Ejaculation is less predictable and may be mixed with urine.
However, urine is sterile, so the clients partner will not get an infection.
4. A nurse cares for a client with a lower motor neuron injury who is experiencing a flaccid bowel elimination
pattern. Which actions should the nurse take to assist in relieving this clients constipation? (Select all that
a. Pour warm water over the perineum.
b. Provide a diet high in fluids and fiber.
c. Administer daily tap water enemas.
d. Implement a consistent daily time for elimination.
e. Massage the abdomen from left to right.
f. Perform manual disimpaction.
ANS: B, D, F
For the client with a lower motor neuron injury, the resulting flaccid bowel may require a bowel program for
the client that includes stool softeners, increased fluid intake, a high-fiber diet, and a consistent elimination
time. If the client becomes impacted, the nurse would need to perform manual disimpaction. Pouring warm
water over the perineum, administering daily enemas, and massaging the abdomen would not assist this client.
5. A nurse assesses a client who is recovering from a lumbar laminectomy. Which complications should alert
the nurse to urgently communicate with the health care provider? (Select all that apply.)
a. Surgical discomfort
b. Redness and itching at the incision site
c. Incisional bulging
d. Clear drainage on the dressing
e. Sudden and severe headache
ANS: C, D, E
Bulging at the incision site or clear fluid on the dressing after a laminectomy strongly suggests a cerebrospinal
fluid leak, which constitutes an emergency. Loss of cerebral spinal fluid may cause a sudden and severe
headache, which is also an emergency situation. Pain, redness, and itching at the site are normal.
6. A nurse assesses a client with paraplegia from a spinal cord injury and notes reddened areas over the clients
hips and sacrum. Which actions should the nurse take? (Select all that apply.)
a. Apply a barrier cream to protect the skin from excoriation.
b. Perform range-of-motion (ROM) exercises for the hip joint.
c. Re-position the client off of the reddened areas.
d. Get the client out of bed and into a chair once a day.
e. Obtain a low-air-loss mattress to minimize pressure.
ANS: C, E
Appropriate interventions to relieve pressure on these areas include frequent re-positioning and a low-air-loss
mattress. Reddened areas should not be rubbed because this action could cause more extensive damage to the
already fragile capillary system. Barrier cream will not protect the skin from pressure wounds. ROM exercises
are used to prevent contractures. Sitting the client in a chair once a day will decrease the clients risk of
respiratory complications but will not decrease pressure on the clients hips and sacrum.
7. A nurse assesses a client who experienced a spinal cord injury at the T5 level 12 hours ago. Which
manifestations should the nurse correlate with neurogenic shock? (Select all that apply.)
a. Heart rate of 34 beats/min
b. Blood pressure of 185/65 mm Hg
c. Urine output less than 30 mL/hr
d. Decreased level of consciousness
e. Increased oxygen saturation
ANS: A, C, D
Neurogenic shock with acute spinal cord injury manifests with decreased oxygen saturation, symptomatic
bradycardia, decreased level of consciousness, decreased urine output, and hypotension.
8. A nurse plans care for a client with a halo fixator. Which interventions should the nurse include in this
clients plan of care? (Select all that apply.)
a. Tape a halo wrench to the clients vest.
b. Assess the pin sites for signs of infection.
c. Loosen the pins when sleeping.
d. Decrease the clients oral fluid intake.
e. Assess the chest and back for skin breakdown.
ANS: A, B, E
A special halo wrench should be taped to the clients vest in case of a cardiopulmonary emergency. The nurse
should assess the pin sites for signs of infection or loose pins and for complications from the halo. The nurse
should also increase fluids and fiber to decrease bowel straining and assess the clients chest and back for skin
breakdown from the halo vest.
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