Chapter 65: Spinal Cord and Peripheral Nerve Problems

Which information would the nurse seek from a patient with newly diagnosed trigeminal neuralgia?

Triggers leading to facial discomfort

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

Inspecting the oral mucosa and teeth

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

Assess fluid and dietary intake.

The nurse identifies a patient with type 1 diabetes and a history of herpes simplex infection as being at risk for Bell‘s palsy. Which information would the nurse include in teaching the patient?

“Call the HCP promptly if you have pain near the ear or facial muscle weakness.”

A patient with Bell‘s palsy refuses to eat while others are present because of embarrassment about drooling. Which action would directly address the patient‘s concerns?

Respect the patient‘s feelings and arrange for privacy at mealtimes.

To prevent autonomic dysreflexia, which nursing action would the home health nurse include in the plan of care for a patient who has paraplegia at the T4 level?

Assist to plan a prescribed bowel program.

Which assessment data for a patient who has Guillain-Barré syndrome requires the nurse‘s most immediate action?

The patient is continuously drooling saliva.

A patient hospitalized with a new diagnosis of Guillain-Barré syndrome has numbness and weakness of both feet. Which intervention would the nurse anticipate?

Infusion of immunoglobulin

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. Which intervention would the nurse anticipate?

Administration of the tetanus-diphtheria (Td) booster

The nurse is admitting a patient who has a neck fracture at the C6 level to the intensive care unit. Which findings on the nursing assessment would indicate neurogenic shock?

Hypotension and warm extremities

A patient has an incomplete left spinal cord lesion at the level of T7, resulting in

Brown-Séquard syndrome. Which action would the nurse include in the plan of care?

Positioning the patient‘s left leg when turning the patient

Which information would the nurse explain to the patient who has a T2 spinal cord transection injury?

Function of both arms would be preserved.

A patient with paraplegia resulting from a T9 spinal cord injury has a neurogenic spastic bladder. Which action would the nurse include in the plan of care?

Instruct the patient how to self-catheterize.

Which goal would the nurse include in a rehabilitation plan for a 30-yr-old patient with a C6 spinal cord injury?

Propel a manual wheelchair on a flat surface.

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 would the nurse take?

Ask the patient to provide input for the plan of care.

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. Which nursing action would best match the goals for this phase of rehabilitation?

Develop a plan to increase the patient‘s independence in consultation with the

patient and the spouse.

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

Assessment of respiratory rate and effort

A patient is hospitalized with new onset of Guillain-Barré syndrome. Which assessment would the nurse recognize as the most essential to complete?

Observing respiratory rate and effort

A patient who had a C7 spinal cord injury 1 week ago has a weak cough effort and crackles. Which initial intervention would the nurse perform?

Push upward on the epigastric area as the patient coughs.

A patient with a history of T3 spinal cord injury is admitted with dermal ulcers. The patient tells the nurse, “I have a pounding headache and I feel sick to my stomach.” Which action would the nurse take first?

Assess the blood pressure (BP).

A patient is being evaluated for a possible spinal cord tumor. Which finding would the nurse recognize as requiring the most immediate action?

The patient has new-onset weakness of both legs.

Which nursing action for a patient with Guillain-Barré syndrome would the nurse identify as appropriate to delegate to experienced assistive personnel (AP)?

Performing range of motion to extremities

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

Provide a quiet environment.

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

Catheterize patient every 3 to 4 hours.

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

Patient with Guillain-Barré syndrome who is drooling and having difficulty

swallowing.

Which assessment finding in a patient with a spinal cord tumor requires the most urgent action by the nurse?

Decreased ability to move the legs

A patient with a T4 spinal cord injury asks the nurse if he will be able to be sexually active. Which information would the nurse include in an initial response?

Multiple options are available to maintain sexuality after spinal cord injury.