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IGGY Chapter 43- Care of patients with problems of the CNS
Terms in this set (30)
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.
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.
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 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
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.
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
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.
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.
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)
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.
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 further disability.
d. When new discoveries are made regarding paraplegia, people in rehabilitation programs will benefit first.
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.
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
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)
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
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.
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
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 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
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
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?
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?
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
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.
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.
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 apply.)
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.
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
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.
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
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.
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