Neurological

During assessment of the patient with trigeminal neuralgia, what should you do (select all that apply)?
A. Inspect all aspects of the mouth and teeth.
B. Assess the gag reflex and respiratory rate and depth.
C. Lightly palpate the affected side of the face for edema.
D. Test for temperature and sensation perception on the face.
E. Ask the patient to describe factors that initiate an episode.

A. Inspect all aspects of the mouth and teeth.
D. Test for temperature and sensation perception on the face.
E. Ask the patient to describe factors that initiate an episode.
Assessment of the attacks, including the triggering factors, characteristics, frequency, and pain management techniques, helps you plan patient care. The painful episodes are usually initiated by a triggering mechanism of light cutaneous stimulation at a specific point (trigger zone) along the distribution of the nerve branches. Precipitating stimuli include chewing, tooth brushing, a hot or cold blast of air on the face, washing the face, yawning, and talking. Touch and tickle seem to predominate as causative triggers, rather than pain or changes in temperature.

Which clinical manifestation do you interpret as representing neurogenic shock in a patient with acute spinal cord injury?
A. Bradycardia
B. Hypertension
C. Neurogenic spasticity
D. Bounding pedal pulses

A. Bradycardia
Neurogenic shock results from loss of vasomotor tone caused by injury and is characterized by hypotension and bradycardia. Loss of sympathetic innervation causes peripheral vasodilation, venous pooling, and a decreased cardiac output.

When planning care for a patient with a C5 spinal cord injury, which nursing diagnosis is the highest priority?
A. Impaired tissue integrity due to paralysis
B. Impaired urinary elimination due to quadriplegia
C. Ineffective coping due to the extent of trauma
D. Ineffective airway clearance due to high cervical spinal cord injury

D. Ineffective airway clearance due to high cervical spinal cord injury
Maintaining a patent airway is the most important goal for a patient with a high cervical fracture. Although all of these options are appropriate nursing diagnoses for a patient with a spinal cord injury, respiratory needs are always the highest priority. Remember the ABCs.

Which signs and symptoms in a patient with a T4 spinal cord injury should alert you to the possibility of autonomic dysreflexia?
A. Headache and rising blood pressure
B. Irregular respirations and shortness of breath
C. Decreased level of consciousness or hallucinations
D. Abdominal distention and absence of bowel sounds

A. Headache and rising blood pressure
Among the manifestations of autonomic dysreflexia are hypertension (up to 300 mm Hg systolic) and throbbing headache. Respiratory manifestations, decreased level of consciousness, and gastrointestinal manifestations are not characteristic.

Which intervention should you perform in the acute care of a patient with autonomic dysreflexia?
A. Urinary catheterization
B. Administration of benzodiazepines
C. Suctioning of the patient's upper airway
D. Placement of the patient in the Trendelenburg position

A. Urinary catheterization
Because the most common cause of autonomic dysreflexia is bladder irritation, immediate catheterization to relieve bladder distention may be necessary. The patient should be positioned upright. Benzodiazepines are contraindicated, and suctioning is likely unnecessary.

A patient is admitted to the intensive care unit (ICU) with a C7 spinal cord injury and diagnosed with Brown-Séquard syndrome. What would you most likely find on physical examination?
A. Upper extremity weakness only
B. Complete motor and sensory loss below C7
C. Loss of position sense and vibration in both lower extremities
D. Ipsilateral motor loss and contralateral sensory loss below C7

D. Ipsilateral motor loss and contralateral sensory loss below C7
Brown-Séquard syndrome is a result of damage to one half of the spinal cord. This syndrome is characterized by a loss of motor function and position and vibratory sense, as well as vasomotor paralysis on the same side (ipsilateral) as the lesion. The opposite (contralateral) side has loss of pain and temperature sensation below the level of the lesion.

A patient is admitted to the hospital with a C4 spinal cord injury after a motorcycle collision. The patient's blood pressure is 83/49 mm Hg and pulse is 39 beats/minute. He remains orally intubated. What is the cause of this pathophysiologic response?
A. Increased vasomotor tone after the injury
B. A temporary loss of sensation and flaccid paralysis below the level of injury
C. Loss of parasympathetic nervous system innervation resulting in vasoconstriction
D. Loss of sympathetic nervous system innervation resulting in peripheral vasodilation

D. Loss of sympathetic nervous system innervation resulting in peripheral vasodilation
eurogenic shock results from loss of vasomotor tone caused by injury, and it is characterized by hypotension and bradycardia. Loss of sympathetic nervous system innervation causes peripheral vasodilation, venous pooling, and a decreased cardiac output. These effects usually are associated with a cervical or high thoracic injury (T6 or higher).

What are the goals of rehabilitation for the patient with an injury at the C6 level (select all that apply)?
A. Stand erect with leg brace
B. Feed self with hand devices
C. Drive an electric wheelchair
D. Assist with transfer activities
E. Drive adapted van from wheel chair

B. Feed self with hand devices
C. Drive an electric wheelchair
D. Assist with transfer activities
E. Drive adapted van from wheel chair
Rehabilitation goals for a patient with a spinal cord injury at the C6 level include ability to assist with transfer and perform some self-care; feed self with hand devices; push wheelchair on smooth, flat surface; drive adapted van from wheelchair; independent computer use with adaptive equipment; and needing attendant care only for 6 hours per day.

A patient with a C7 spinal cord injury undergoing rehabilitation tells you he must have the flu because he has a bad headache and nausea. What is your initial action?
A. Call the physician.
B. Check the patient's temperature.
C. Take the patient's blood pressure.
D. Elevate the head of the bed to 90 degrees.

C. Take the patient's blood pressure.
Autonomic dysreflexia is a massive, uncompensated cardiovascular reaction mediated by the sympathetic nervous system. Manifestations include hypertension (up to 300 mm Hg systolic), throbbing headache, marked diaphoresis above the level of the lesion, bradycardia (30 to 40 beats/minute), piloerection, flushing of the skin above the level of the lesion, blurred vision or spots in the visual fields, nasal congestion, anxiety, and nausea. It is important to measure blood pressure when a patient with a spinal cord injury complains of a headache.

For a 65-year-old female patient who has lived with a T1 spinal cord injury for 20 years, which health teaching information should you emphasize?
A. A mammogram is needed every year.
B. Bladder function tends to improve with age.
C. Heart disease is not common in persons with spinal cord injury.
D. As a person ages, the need to change body position is less important.

A. A mammogram is needed every year.
Health promotion and screening are important for the older patient with a spinal cord injury. Older adult women with spinal cord injuries should perform monthly breast examinations and yearly mammograms

Which condition is transmitted through wound contamination, causes painful tonic spasms or seizures, and can be
prevented by immunization?
a. Tetanus
b. Botulism
c. Neurosyphilis
d. Systemic inflammatory response syndrome

a. Tetanus is transmitted through wound contamination,
causes painful tonic spasms or seizures, and can be
prevented with immunization.

In planning community education for prevention of spinal cord injuries, what group should the nurse target?
a. Older men
b. Teenage girls
c. Elementary school-age children
d. Adolescent and young adult men

d. Spinal cord injuries are highest in adolescent and
young adult men between the ages of 16 and 30 and
those who are impulsive or risk takers in daily living.
Other risk factors include alcohol and drug abuse as well
as participation in sports and occupational exposure to
trauma or violence.

A 70-year-old patient is admitted after falling from his roof. He has a spinal cord injury at the C7 level. What
findings during the assessment identify the presence of spinal shock?
a. Paraplegia with a flaccid paralysis
b. Tetraplegia with total sensory loss
c. Total hemiplegia with sensory and motor loss
d. Spastic tetraplegia with loss of pressure sensation

b. At the C7 level, spinal shock is manifested by
tetraplegia and sensory loss. The neurologic loss may be
temporary or permanent. Paraplegia with sensory loss
would occur at the level of T1. A hemiplegia occurs with
central (brain) lesions affecting motor neurons and spastic
tetraplegia occurs when spinal shock resolves.

Which syndrome of incomplete spinal cord lesion is described as cord damage common in the cervical region
resulting in greater weakness in upper extremities than lower?
a. Central cord syndrome
b. Anterior cord syndrome
c. Posterior cord syndrome
d. Cauda equina and conus medullaris syndromes

a. In central cord syndrome, motor weakness and sensory
loss are present in both upper and lower extremities, with
upper extremities affected more than lower extremities.

The patient is diagnosed with Brown-Séquard syndrome after a knife wound to the spine. Which description
accurately describes this syndrome?
a. Damage to the most distal cord and nerve roots, resulting in flaccid paralysis of the lower limbs and areflexic
bowel and bladder
b. Spinal cord damage resulting in ipsilateral motor paralysis and contralateral loss of pain and sensation below the
level of the lesion
c. Rare cord damage resulting in loss of proprioception below the lesion level with retention of motor control and
temperature and pain sensation
d. Often caused by flexion injury with acute compression of cord resulting in complete motor paralysis and loss of
pain and temperature sensation below the level of injury

b. Brown-Séquard syndrome is characterized by ipsilateral
loss of motor function and position and vibratory sense
and vasomotor paralysis with contralateral loss of pain
and temperature sensation below the level of the injury.
Damage to the most distal cord and nerve roots with
flaccid paralysis of the lower limbs and areflexic bowel
and bladder is seen with cauda equine syndrome or conus
medullaris syndrome. Posterior cord syndrome is rare, with
cord damage resulting in loss of proprioception below the
lesion level but retention of motor control and temperature
and pain sensation. Anterior cord syndrome is often caused
by flexion injury, with acute compression of the cord
resulting in complete motor paralysis and loss of pain and
temperature sensation below the level of injury but touch,
position, vibration, and motion remaining intact.

What causes an initial incomplete spinal cord injury to result in complete cord damage?
a. Edematous compression of the cord above the level of the injury
b. Continued trauma to the cord resulting from damage to stabilizing ligaments
c. Infarction and necrosis of the cord caused by edema, hemorrhage, and metabolites
d. Mechanical transection of the cord by sharp vertebral bone fragments after the initial injury

c. The primary injury of the spinal cord rarely affects
the entire cord but the pathophysiology of secondary
injury may result in damage that is the same as
mechanical severance of the cord. Complete cord
dissolution occurs through autodestruction of the cord by
hemorrhage, edema, and the presence of metabolites and
norepinephrine, resulting in anoxia and infarction of the
cord. Edema resulting from the inflammatory response
may compress the spinal cord as well as increase the
damage as it extends above and below the injury site.

A patient with a spinal cord injury has spinal shock. The nurse plans care for the patient based on what knowledge?
a. Rehabilitation measures cannot be initiated until spinal shock has resolved.
b. The patient will need continuous monitoring for hypotension, tachycardia, and hypoxemia.
c. Resolution of spinal shock is manifested by spasticity, hyperreflexia, and reflex emptying of the bladder.
d. The patient will have complete loss of motor and sensory functions below the level of the injury but autonomic
functions are not affected.

c. Spinal shock occurs in about half of all people with
acute spinal cord injury. In spinal shock, the entire
cord below the level of the lesion fails to function,
resulting in a flaccid paralysis and hypomotility of most
processes without any reflex activity. Return of reflex
activity, although hyperreflexive and spastic, signals
the end of spinal shock. Rehabilitation activities are
not contraindicated during spinal shock and should be
instituted if the patient's cardiopulmonary status is stable.
Neurogenic shock results from loss of vascular tone caused by the injury and is manifested by hypotension,
peripheral vasodilation, and decreased cardiac output
(CO). Sympathetic function is impaired below the level
of the injury because sympathetic nerves leave the
spinal cord at the thoracic and lumbar areas and cranial
parasympathetic nerves predominate in control over
respirations, heart, and all vessels and organs below the
injury, which includes autonomic functions.

Two days following a spinal cord injury, a patient asks continually about the extent of impairment that will result
from the injury. What is the best response by the nurse?
a. "You will have more normal function when spinal shock resolves and the reflex arc returns."
b. "The extent of your injury cannot be determined until the secondary injury to the cord is resolved."
c. "When your condition is more stable, MRI will be done to reveal the extent of the cord damage."
d. "Because long-term rehabilitation can affect the return of function, it will be years before we can tell what the
complete effect will be."

b. Until the edema and necrosis at the site of the injury
are resolved in 72 hours to 1 week after the injury, it
is not possible to determine how much cord damage is
present from the initial injury, how much secondary injury
occurred, or how much the cord was damaged by edema
that extended above the level of the original injury. The
return of reflexes signals only the end of spinal shock and
the reflexes may be inappropriate and excessive, causing
spasms that complicate rehabilitation.

Priority Decision: The patient was in a traffic collision and is experiencing loss of function below C4. Which effect
must the nurse be aware of to provide priority care for the patient?
a. Respiratory diaphragmatic breathing
b. Loss of all respiratory muscle function
c. Decreased response of the sympathetic nervous system
d. GI hypomotility with paralytic ileus and gastric distention

a. Spinal injury below C4 will result in diaphragmatic
breathing and usually hypoventilation from decreased
vital capacity and tidal volume from intercostal muscle
impairment. The nurse's priority actions will be to
monitor rate, rhythm, depth, and effort of breathing to
observe for changes from the baseline and identify the
need for ventilation assistance. Loss of all respiratory
muscle function occurs above C4 and the patient requires
mechanical ventilation to survive. Although the decreased
sympathetic nervous system response (from injuries
above T6) and GI hypomotility (paralytic ileus and gastric
distention) will occur (with injuries above T5), they are
not the patient's initial priority needs.

A patient is admitted to the emergency department with a spinal cord injury at the level of T2. Which finding is of
most concern to the nurse?
a. SpO2 of 92%
b. Heart rate of 42 bpm
c. Blood pressure of 88/60 mm Hg
d. Loss of motor and sensory function in arms and legs

b. Neurogenic shock associated with cord injuries
above the level of T6 greatly decreases the effect of
the sympathetic nervous system and bradycardia and
hypotension occur. A heart rate of 42 bpm is not adequate
to meet the oxygen needs of the body. While low, the
blood pressure is not at a critical point. The oxygen
saturation is satisfactory and the motor and sensory losses
are expected.

The patient's spinal cord injury is at T4. What is the highest-level goal of rehabilitation that is realistic for this patient
to have?
a. Indoor mobility in manual wheelchair
b. Ambulate with crutches and leg braces
c. Be independent in self-care and wheelchair use
d. Completely independent ambulation with short leg braces and canes

c. With the injury at T4, the highest-level realistic goal for
this patient is to be able to be independent in self-care and
wheelchair use because arm function will not be affected.
Indoor mobility in a manual wheelchair will be achievable
but it is not the highest-level goal. Ambulating with
crutches and leg braces can be achieved only by patients
with injuries in T6-12 area. Independent ambulation with
short leg braces and canes could occur for a patient with
an L3-4 injury. (See Table 61-4.)

What is one indication for early surgical therapy of the patient with a spinal cord injury?
a. There is incomplete cord lesion involvement.
b. The ligaments that support the spine are torn.
c. A high cervical injury causes loss of respiratory function.
d. Evidence of continued compression of the cord is apparent.

d. Although surgical treatment of spinal cord injuries often
depends on the preference of the health care provider,
surgery is usually indicated when there is continued
compression of the cord by extrinsic forces or when there
is evidence of cord compression. Other indications may
include progressive neurologic deficit, compound fracture
of the vertebra, bony fragments, and penetrating wounds
of the cord.

Priority Decision: A patient is admitted to the emergency department with a possible cervical spinal cord injury
following an automobile crash. During admission of the patient, what is the highest priority for the nurse?
a. Maintaining a patent airway
b. Maintaining immobilization of the cervical spine
c. Assessing the patient for head and other injuries
d. Assessing the patient's motor and sensory function

a. The need for a patent airway is the first priority for any
injured patient and a high cervical injury may decrease the
gag reflex and the ability to maintain an airway as well as
the ability to breathe. Maintaining cervical stability is then
a consideration, along with assessing for other injuries and
the patient's neurologic status.

Without surgical stabilization, what method of immobilization for the patient with a cervical spinal cord injury
should the nurse expect to be used?
a. Kinetic beds
b. Hard cervical collar
c. Skeletal traction with skull tongs
d. Sternal-occipital-mandibular immobilizer brace

c. The development of better surgical stabilization has
made surgery the more frequent treatment of cervical
injuries. However, when surgery cannot be done,
skeletal traction with the use of Crutchfield, Vinke, or
other types of skull tongs is required to immobilize
the cervical vertebrae, even if a fracture has not
occurred. Hard cervical collars or a sternal-occipitalmandibular
immobilizer brace may be used after cervical
stabilization surgery or for minor injuries or stabilization
during emergency transport of the patient. Sandbags
may also be used temporarily to stabilize the neck
during insertion of tongs or during diagnostic testing
immediately following the injury. Special turning or
kinetic beds may be used to turn and mobilize patients
who are in cervical traction.

The health care provider has ordered IV dopamine (Intropin) for a patient in the emergency department with a
spinal cord injury. The nurse determines that the drug is having the desired effect when what is observed in patient
assessment?
a. Heart rate of 68 bpm
b. Respiratory rate of 24
c. Blood pressure of 106/82 mm Hg
d. Temperature of 96.8°F (36.0°C)

c. Dopamine is a vasopressor that is used to maintain
blood pressure during states of hypotension that occur
during neurogenic shock associated with spinal cord
injury. Atropine would be used to treat bradycardia. The
temperature reflects some degree of poikilothermism but
this is not treated with medications.

Priority Decision: During assessment of a patient with a spinal cord injury, the nurse determines that the patient has
a poor cough with diaphragmatic breathing. Based on this finding, what should be the nurse's first action?
a. Institute frequent turning and repositioning.
b. Use tracheal suctioning to remove secretions.
c. Assess lung sounds and respiratory rate and depth.
d. Prepare the patient for endotracheal intubation and mechanical ventilation.

c. Because pneumonia and atelectasis are potential
problems related to ineffective coughing and the loss of
intercostal and abdominal muscle function, the nurse
should assess the patient's breath sounds and respiratory
function to determine whether secretions are being retained
or whether there is progression of respiratory impairment.
Suctioning is not indicated unless lung sounds indicate
retained secretions. Position changes will help to mobilize
secretions. Intubation and mechanical ventilation are used
if the patient becomes exhausted from labored breathing or
if arterial blood gases (ABGs) deteriorate.

Following a T2 spinal cord injury, the patient develops paralytic ileus. While this condition is present, what should
the nurse anticipate that the patient will need?
a. IV fluids
b. Tube feedings
c. Parenteral nutrition
d. Nasogastric suctioning

d. During the first 2 to 3 days after a spinal cord injury,
paralytic ileus may occur and nasogastric suction must be
used to remove secretions and gas from the GI tract until
peristalsis resumes. IV fluids are used to maintain fluid
balance but do not specifically relate to paralytic ileus.
Tube feedings would be used only for patients who have
difficulty swallowing and not until peristalsis returns.
Parenteral nutrition would be used only if the paralytic
ileus was unusually prolonged.

How is urinary function maintained during the acute phase of spinal cord injury?
a. An indwelling catheter
b. Intermittent catheterization
c. Insertion of a suprapubic catheter
d. Use of incontinent pads to protect the skin

a. During the acute phase of spinal cord injury, the bladder
is hypotonic, causing urinary retention with the risk
for reflux into the kidney or rupture of the bladder. An
indwelling catheter is used to keep the bladder empty and
to monitor urinary output. Intermittent catheterization
or other urinary drainage methods may be used in longterm
bladder management. Use of incontinent pads is
inappropriate because they do not help the bladder to
empty.

A week following a spinal cord injury at T2, a patient experiences movement in his leg and tells the nurse that he is
recovering some function. What is the nurse's best response to the patient?
a. "It is really still too soon to know if you will have a return of function."
b. "That could be a really positive finding. Can you show me the movement?"
c. "That's wonderful. We will start exercising your legs more frequently now."
d. "I'm sorry but the movement is only a reflex and does not indicate normal function."

b. When spinal shock ends, reflex movement and spasms
will occur, which may be mistaken for return of function;
however, with the resolution of edema, some normal
function may also occur. It is important when movement
occurs to determine whether the movement is voluntary
and can be consciously controlled, which would indicate
some return of function.

A patient with paraplegia has developed an irritable bladder with reflex emptying. What will be most helpful for the
nurse to teach the patient?
a. Hygiene care for an indwelling urinary catheter
b. How to perform intermittent self-catheterization
c. To empty the bladder with manual pelvic pressure in coordination with reflex voiding patterns
d. That a urinary diversion, such as an ileal conduit, is the easiest way to handle urinary elimination

b. Intermittent self-catheterization five to six times a day is
the recommended method of bladder management for the
patient with a spinal cord injury and reflexic neurogenic
bladder because it more closely mimics normal emptying
and has less potential for infection. The patient and family
should be taught the procedure using clean technique
and if the patient has use of the arms, self-catheterization
should be performed. Indwelling catheterization is used
during the acute phase to prevent overdistention of the
bladder and surgical urinary diversions are used if urinary
complications occur.

In counseling patients with spinal cord lesions regarding sexual function, how should the nurse advise a male patient
with a complete lower motor neuron lesion?
a. He is most likely to have reflexogenic erections and may experience orgasm if ejaculation occurs.
b. He may have uncontrolled reflex erections but orgasm and ejaculation are usually not possible.
c. He has a lesion with the greatest possibility of successful psychogenic erection with ejaculation and orgasm.
d. He will probably be unable to have either psychogenic or reflexogenic erections and no ejaculation or orgasm.

d. Most patients with a complete lower motor neuron lesion
are unable to have either psychogenic or reflexogenic
erections and alternative methods of obtaining sexual
satisfaction may be suggested. Patients with incomplete
lower motor neuron lesions have the highest possibility of
successful psychogenic erections with ejaculation whereas
patients with incomplete upper motor neuron lesions are
more likely to experience reflexogenic erections with
ejaculation. Patients with complete upper motor neuron
lesions usually have only reflex sexual function with rare
ejaculation.

During the patient's process of grieving for the losses resulting from spinal cord injury, what should the nurse do?
a. Help the patient to understand that working through the grief will be a lifelong process.
b. Assist the patient to move through all stages of the mourning process to acceptance.
c. Let the patient know that anger directed at the staff or the family is not a positive coping mechanism.
d. Facilitate the grieving process so that it is completed by the time the patient is discharged from rehabilitation.

a. Working through the grief process is a lifelong process
that is triggered by new experiences, such as marriage,
child rearing, employment, or illness, which the patient
must adjust to throughout life within the context of
his or her disability. The goal of recovery is related to
adjustment rather than acceptance and many patients do
not experience all components of the grief process. During
the anger phase, patients should be allowed outbursts and
the nurse may use humor to displace some of the patient's
anger.

Which is most important to respond to in a patient presenting with a T3 spinal injury?
A. Blood pressure of 88/60 mm Hg, pulse of 56 beats/minute
B. Deep tendon reflexes of 1+, muscle strength of 1+
C. Pain rated at 9
D. Warm, dry skin

A. Blood pressure of 88/60 mm Hg, pulse of 56 beats/minute
Neurogenic shock is a loss of vasomotor tone caused by injury, and it is characterized by hypotension and bradycardia. The loss of sympathetic nervous system innervations causes peripheral vasodilation, venous pooling, and a decreased cardiac output. The other options can be expected findings and are not as significant. Patients in neurogenic shock have pink and dry skin, instead of cold and clammy, but this sign is not as important as the vital signs.

One month after a spinal cord injury, which finding is most important for you to monitor?
A. Bladder scan indicates 100 mL.
B. The left calf is 5 cm larger than the right calf.
C. The heel has a reddened, nonblanchable area.
D. Reflux bowel emptying.

B. The left calf is 5 cm larger than the right calf.
Deep vein thrombosis is a common problem accompanying spinal cord injury during the first 3 months. Pulmonary embolism is one of the leading causes of death. Common signs and symptoms are absent. Assessment includes Doppler examination and measurement of leg girth. The other options are not as urgent to deal with as potential deep vein thrombosis.

What is most important action for a patient who has a suspected cervical spinal injury?
A. Apply a soft foam cervical collar.
B. Perform a neurologic check.
C. Place the patient on a firm surface.
D. Assess function of cranial nerves IX and X.

C. Place the patient on a firm surface.
A patient with a suspected cervical spine injury should be immobilized with a hard collar and placed on a firm surface. This takes priority over any further assessment. A soft foam collar does not provide immobilization.

The patient arrives in the emergency department from a motor vehicle accident, during which the car ran into a tree. The patient was not wearing a seat belt, and the windshield is shattered. What action is most important for you to do?
A. Determine if the patient lost consciousness.
B. Assess the Glasgow Coma Scale (GCS) score.
C. Obtain a set of vital signs.
D. Use a logroll technique when moving the patient.

D. Use a logroll technique when moving the patient.
When the head hits the windshield with enough force to shatter it, you must assume neck or cervical spine trauma occurred and you need to maintain spinal precautions. This includes moving the patient in alignment as a unit or using a logroll technique during transfers. The other options are important and are done after spinal precautions are applied.

Which patient should be assigned to the experienced registered nurse on a neurologic floor?
A. Patient with trigeminal neuralgia reporting facial pain rated at 10
B. Patient with Bell's palsy with unilateral facial droop
C. Patient after surgical removal of a spinal cord tumor who is scheduled for discharge tomorrow
D. Patient with traumatic injury to the cervical spinal cord who was admitted today from the emergency department

D. Patient with traumatic injury to the cervical spinal cord who was admitted today from the emergency department
The patient with the cervical spinal cord injury is potentially the most unstable and needs an experienced, professional nurse.

You are caring for a patient admitted with a spinal cord injury after a motor vehicle accident. The patient exhibits a complete loss of motor, sensory, and reflex activity below the injury level. What is this condition?

A. Central cord syndrome
B. Spinal shock syndrome
C. Anterior cord syndrome
D. Brown-Séquard syndrome

B. Spinal shock syndrome
About 50% of people with acute spinal cord injury experience a temporary loss of reflexes, sensation, and motor activity that is known as spinal shock. Central cord syndrome is manifested by motor and sensory loss greater in the upper extremities than the lower extremities. Anterior cord syndrome results in motor and sensory loss but not loss of reflexes. Brown-Séquard syndrome is characterized by ipsilateral loss of motor function and contralateral loss of sensory function.

Which clinical manifestation do you interpret as representing neurogenic shock in a patient with acute spinal cord injury?

A. Bradycardia
B. Hypertension
C. Neurogenic spasticity
D. Bounding pedal pulses

A. Bradycardia
Neurogenic shock results from loss of vasomotor tone caused by injury and is characterized by hypotension and bradycardia. Loss of sympathetic innervation causes peripheral vasodilation, venous pooling, and a decreased cardiac output. Thus hypertension, neurogenic spasticity, and bounding pedal pulses are not seen in neurogenic shock.

You are caring for a patient admitted 1 week earlier with an acute spinal cord injury. Which assessment finding alerts you to the presence of autonomic dysreflexia?
A. Tachycardia
B. Hypotension
C. Hot, dry skin
D. Throbbing headache

D. Throbbing headache
Autonomic dysreflexia is related to reflex stimulation of the sympathetic nervous system, which is reflected by hypertension, bradycardia, throbbing headache, and diaphoresis.

When planning care for a patient with a C5 spinal cord injury, which nursing diagnosis is the highest priority?

A. Impaired tissue integrity due to paralysis
B. Impaired urinary elimination due to quadriplegia
C. Ineffective coping due to the extent of trauma
D. Ineffective airway clearance due to high cervical spinal cord injury

D. Ineffective airway clearance due to high cervical spinal cord injury
Maintaining a patent airway is the most important goal for a patient with a high cervical fracture. Although all of these options are appropriate nursing diagnoses for a patient with a spinal cord injury, respiratory needs are always the highest priority. Remember the ABCs.

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Which intervention should you perform in the acute care of a patient with autonomic dysreflexia?

A. Urinary catheterization
B. Administration of benzodiazepines
C. Suctioning of the patient's upper airway
D. Placement of the patient in the Trendelenburg position

A. Urinary catheterization
Because the most common cause of autonomic dysreflexia is bladder irritation, immediate catheterization to relieve bladder distention may be necessary. Benzodiazepines are contraindicated, and suctioning is likely unnecessary. The patient should be positioned upright.

A 68-year-old patient with a spinal cord injury has a neurogenic bowel. Beyond the use of bisacodyl (Dulcolax) suppositories and digital stimulation, which measures should the nurse teach the patient and the caregiver to assist the patient with bowel evacuation (select all that apply)?

A. Drink more milk.
B. Eat 20-30 g of fiber per day.
C. Use oral laxatives every day.
D. Drink 1800 to 2800 mL of water or juice.
D. Establish bowel evacuation time at bedtime.

B, D,
The patient with a spinal cord injury and neurogenic bowel should eat 20-30 g of fiber and drink 1800 to 2800 mL of water or juice each day. Milk may cause constipation. Daily oral laxatives may cause diarrhea and are avoided unless necessary. Bowel evacuation time is usually established 30 minutes after the first meal of the day to take advantage of the gastrocolic reflex induced by eating.

A 25-year-old male patient who is a professional motocross racer has anterior spinal cord syndrome at T10. His history is significant for tobacco, alcohol, and marijuana use. What is the nurse's priority during rehabilitation?

A. Prevent urinary tract infections.
B. Monitor the patient every 15 minutes.
C. Encourage him to verbalize his feelings.
D. Teach him about using the gastrocolic reflex.

C
To help him with his coping and prevent self-harm, the nurse should create a therapeutic patient environment that encourages his self-expression and verbalization of thoughts and feelings. This patient is at high risk for depression and self-injury because he is likely to lose function below the umbilicus involving lost motor and sensory function. In addition, he is a young adult male patient who is likely to need a wheelchair, have impaired sexual function, and is unlikely to resume his racing career. Because the patient uses tobacco, alcohol, and marijuana frequently, hospitalization is likely to result in a loss of these habits that can make coping especially difficult for him. Prevention of urinary tract infections and facilitating bowel evacuation with the gastrocolic reflex will be important but not as important as helping him cope. In rehabilitation, monitoring every 15 minutes is not needed unless he is on a suicide watch.

A patient is admitted to the intensive care unit (ICU) with a C7 spinal cord injury and diagnosed with Brown-Séquard syndrome. What would you most likely find on physical examination?

A. Upper extremity weakness only
B. Complete motor and sensory loss below C7
C. Loss of position sense and vibration in both lower extremities
D. Ipsilateral motor loss and contralateral sensory loss below C7

D. Ipsilateral motor loss and contralateral sensory loss below C7
Brown-Séquard syndrome is a result of damage to one half of the spinal cord. This syndrome is characterized by a loss of motor function, position sense, and vibratory sense, as well as by vasomotor paralysis on the same side (ipsilateral) as the injury. The opposite (contralateral) side has loss of pain and temperature sensation below the level of the injury.

A patient is admitted to the hospital with a C4 spinal cord injury after a motorcycle collision. The patient's blood pressure is 83/49 mm Hg and pulse is 39 beats/minute. He remains orally intubated. What is the cause of this pathophysiologic response?

A. Increased vasomotor tone after the injury
B. A temporary loss of sensation and flaccid paralysis below the level of injury
C. Loss of parasympathetic nervous system innervation resulting in vasoconstriction
D. Loss of sympathetic nervous system innervation resulting in peripheral vasodilation

D. Loss of sympathetic nervous system innervation resulting in peripheral vasodilation
Neurogenic shock results from loss of vasomotor tone caused by injury and is characterized by hypotension and bradycardia. Loss of sympathetic nervous system innervation causes peripheral vasodilation, venous pooling, and a decrease in cardiac output. These effects are usually associated with a cervical or high thoracic injury (T6 or higher).

What are the goals of rehabilitation for the patient with an injury at the C6 level (select all that apply)?

A. Stand erect with leg brace
B. Feed self with hand devices
C. Drive an electric wheelchair
D. Assist with transfer activities
E. Drive adapted van from wheel chair

b, c, d, e
Rehabilitation goals for a patient with a spinal cord injury at the C6 level include the ability to assist with transfer and perform some self-care; feed self with hand devices; push a wheelchair on smooth, flat surfaces; drive an adapted van from a wheelchair; independent computer use with adaptive equipment; and need for attendant care for only 6 hours per day.

A patient with a C7 spinal cord injury undergoing rehabilitation tells you he must have the flu because he has a bad headache and nausea. What is your initial action?

A. Call the physician.
B. Check the patient's temperature.
C. Take the patient's blood pressure.
D. Elevate the head of the bed to 90 degrees.

C. Take the patient's blood pressure.
Autonomic dysreflexia is a massive, uncompensated cardiovascular reaction mediated by the sympathetic nervous system. Manifestations include hypertension (up to 300 mm Hg systolic), throbbing headache, marked diaphoresis above the level of the injury, bradycardia (30 to 40 beats/min), piloerection, flushing of the skin above the level of the injury, blurred vision or spots in the visual fields, nasal congestion, anxiety, and nausea. It is important to measure blood pressure when a patient with a spinal cord injury complains of headache. Other nursing interventions in this serious emergency are elevation of the head of the bed 45 degrees or sitting the patient upright, notification of the physician, and assessment to determine the cause. Table 61-8 lists the causes and symptoms of autonomic dysreflexia. The nurse must monitor blood pressure frequently during the episode. An α-adrenergic blocker or an arteriolar vasodilator may be administered.

For a 65-year-old female patient who has lived with a T1 spinal cord injury for 20 years, which health teaching information should you emphasize?

A. A mammogram is needed every year.
B. Bladder function tends to improve with age.
C. Heart disease is not common in persons with spinal cord injury.
D. As a person ages, the need to change body position is less important.

A. A mammogram is needed every year.
Health promotion and screening are important for an older patient with a spinal cord injury. Older adult women with spinal cord injuries should perform monthly breast examinations and undergo yearly mammography.

What is the primary treatment for a primary neoplasm on the spine?
A. High-dose oral corticosteroids
B. Methylprednisolone IV
C. Chemotherapy
D. Surgery

D. Surgery
Treatment for most spinal cord tumors is surgical removal. Because autodestruction does not occur, recovery without residual problems is possible after the physical compression is relieved.

What is the most common early symptom of a spinal cord tumor?

A. Urinary incontinence
B. Back pain that worsens with activity
C. Paralysis below the level of involvement
D. Impaired sensation of pain, temperature, and light touch

B. Back pain that worsens with activity
The most common early symptom of a spinal cord tumor outside the cord is pain in the back, with radicular pain simulating intercostal neuralgia, angina, or herpes zoster. The location of the pain depends on the level of compression. The pain worsens with activity, coughing, straining, and lying down.

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?
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.

ANS: D
Fecal impaction is a common stimulus for autonomic dysreflexia. The other actions may be included in the plan of care but will not reduce the risk for autonomic dysreflexia.

A patient arrives at an urgent care center with a deep puncture wound after stepping on a nail that was lying on the ground. The patient reports having had a tetanus booster 7 years ago. The nurse will anticipate
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.

ANS: B
If the patient has not been immunized within 5 years, administration of the Td booster is indicated because the wound is deep. Immune globulin administration is given by the IM route if the patient has no previous immunization. Administration of a series of immunization is not indicated. TIG is not indicated for this patient, and a test dose is not needed for immune globulin.

A patient with a neck fracture at the C5 level is admitted to the intensive care unit. During initial assessment of the patient, the nurse recognizes the presence of neurogenic shock on finding
a. hypotension, bradycardia, and warm extremities.
b. involuntary, spastic movements of the arms and legs.
c. hyperactive reflex activity below the level of the injury.
d. lack of movement or sensation below the level of the injury.

ANS: A
Neurogenic shock is characterized by hypotension, bradycardia, and vasodilation leading to warm skin temperature. Spasticity and hyperactive reflexes do not occur at this stage of spinal cord injury. Lack of movement and sensation indicate spinal cord injury, but not neurogenic shock.

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

ANS: B
The patient with a T1 injury can expect to retain full motor and sensory function of the arms. Use of only the shoulders is associated with cervical spine injury. Loss of respiratory function occurs with cervical spine injuries. Bradycardia is associated with injuries above the T6 level.

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?
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.

ANS: B
Because the patient's bladder is spastic and will empty in response to overstretching of the bladder wall, the most appropriate method is to avoid incontinence by emptying the bladder at regular intervals through intermittent catheterization. Assisting the patient to the toilet will not be helpful because the bladder will not empty. The Credé method is more appropriate for a bladder that is flaccid, such as occurs with a reflexic neurogenic bladder. Catheterization after voiding will not resolve the patient's incontinence.

When the nurse is developing a rehabilitation plan for a patient with a C6 spinal cord injury, an appropriate patient goal is that the patient will be able to
a. transfer independently to a wheelchair.
b. drive a car with powered hand controls.
c. turn and reposition independently when in bed.
d. push a manual wheelchair on flat, smooth surfaces.

ANS: D
The patient with a C6 injury will be able to use the hands to push a wheelchair on flat, smooth surfaces. Because flexion of the thumb and fingers is minimal, the patient will not be able to grasp a wheelchair during transfer, drive a car with powered hand controls, or turn independently in bed.

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?
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.

ANS: A
The patient is demonstrating behaviors consistent with the anger phase of the mourning process, and the nurse should allow expression of anger and seek the patient's input into care. Expression of anger is appropriate at this stage and should be tolerated by the nurse. Reassurance about the competency of the staff will not be helpful in responding to the patient's anger. Ignoring the patient's comments will increase the patient's anger and sense of helplessness.

After a 25-year-old patient has returned home following rehabilitation for a spinal cord injury, the home care nurse notes that the spouse is performing many of the activities that the patient had been managing during rehabilitation. The most appropriate action by the nurse at this time is to
a. tell the spouse that the patient can perform activities independently.
b. remind the patient about the importance of independence in daily activities.
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 support the spouse's participation.

ANS: C
The best action by the nurse will be to involve all the parties in developing an optimal plan of care. Because family members who will be assisting with the patient's ongoing care need to feel that their input is important, telling the spouse that the patient can perform activities independently is not the best choice. Reminding the patient about the importance of independence may not change the behaviors of the spouse. Supporting the activities of the spouse will lead to ongoing dependency by the patient.

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

ANS: A
Edema around the area of injury may lead to damage above the C4 level, so the highest priority is assessment of the patient's respiratory function. The other actions also are appropriate but are not as important as assessment of respiratory effort

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
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.

ANS: C
Since the cough effort is poor, the initial action should be to use assisted coughing techniques to improve the ability to mobilize secretions. Administration of oxygen will improve oxygenation, but the data do not indicate hypoxemia. The use of the spirometer may improve respiratory status, but the patient's ability to take deep breaths is limited by the loss of intercostal muscle function. Suctioning may be needed if the patient is unable to expel secretions by coughing but should not be the nurse's first action.

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?
a. Leg strength and sensation
b. Skin temperature and color
c. Blood pressure and apical heart rate
d. Respiratory effort and O2 saturation

ANS: A
The purpose of methylprednisolone administration is to help preserve motor function and sensation. Therefore the nurse will assess this patient for lower extremity function. The other data also will be collected by the nurse, but they do not reflect the effectiveness of the methylprednisolone.

Methylprednisolone is an anti-inflammatory.

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?
a. Assess for a fecal impaction.
b. Give the prescribed antiemetic.
c. Check the blood pressure (BP).
d. Notify the health care provider.

ANS: C
The BP should be assessed immediately in a patient with an injury at the T6 level or higher who complains of a headache to determine whether autonomic dysreflexia is occurring. Notification of the patient's health care provider is appropriate after the BP is obtained. Administration of an antiemetic is indicated after autonomic dysreflexia is ruled out as the cause of the nausea. The nurse may assess for a fecal impaction, but this should be done after checking the BP and lidocaine jelly should be used to prevent further increases in the BP.

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?
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.

ANS: C
Although sexuality will be changed by the patient's spinal cord injury, there are options for expression of sexuality and for fertility. The other information also is correct, but the choices will depend on the degrees of injury and the patient's individual feelings about sexuality.

When caring for a patient who experienced a T1 spinal cord transsection 2 days ago, which collaborative and nursing actions will the nurse include in the plan of care (select all that apply)?
a. Urinary catheter care
b. Nasogastric (NG) tube feeding
c. Continuous cardiac monitoring
d. Avoidance of cool room temperature
e. Administration of H2 receptor blockers

ANS: A, C, D, E
The patient is at risk for bradycardia and poikilothermia caused by sympathetic nervous system dysfunction and should have continuous cardiac monitoring and maintenance of a relatively warm room temperature. Gastrointestinal (GI) motility is decreased initially and NG suctioning is indicated. To avoid bladder distention, a urinary retention catheter is used during this acute phase. Stress ulcers are a common complication but can be avoided through the use of the H2 receptor blockers such as famotidine.

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 answer 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.

ANS:
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.

The nurse cares for a 63-year-old woman taking prednisone (Deltasone) and acyclovir (Zovirax) for Bell's palsy. It is most important for the nurse to follow up on which patient statement?

A. "I can take both medications with food or milk."
B. "I will take these medications for 2 to 3 months."
C. "I can take acetaminophen with the prescribed medications."
D. "Chances of a full recovery are good if I take the medications."

b
Prednisone and acyclovir will usually be prescribed for 10 days. Prednisone will be tapered over the last 4 days of treatment. Oral prednisone and acyclovir may be taken with food or milk to decrease gastrointestinal upset. Patients with Bell's palsy usually begin recovery in 2 to 3 weeks, and most patients have complete recovery in 2 to 3 months. Patients have the best chance for full recovery if prednisone is initiated before complete paralysis occurs. There are no serious drug interactions among prednisone, acyclovir, and acetaminophen.

The nurse performs discharge teaching for a 34-year-old male patient with a T2 spinal cord injury resulting from a construction accident. Which statement, if made by the patient to the nurse, indicates that teaching about recognition and management of autonomic dysreflexia is successful?

A. "I will perform self-catheterization at least six times per day."
B. "A reflex erection may cause an unsafe drop in blood pressure."
C. "If I develop a severe headache, I will lie down for 15 to 20 minutes."
D. "I can avoid this problem by taking medications to prevent leg spasms."

a
Autonomic dysreflexia is usually caused by a distended bladder. Performing self-catheterization five or six times a day prevents bladder distention. Signs and symptoms of autonomic dysreflexia include a severe headache. Patients should raise the head of the bed to 45 to 90 degrees. This action helps to relieve hypertension (systolic pressure up to 300 mm Hg) that occurs with autonomic dysreflexia.

A 19-year-old man is admitted to the emergency department with a C6 spinal cord injury after a motorcycle crash. Which medication should the nurse anticipate that she will administer first?

A. Enoxaparin (Lovenox)
B. Metoclopramide (Reglan)
C. IV immunoglobulin (Sandoglobulin)
D. Methylprednisolone sodium succinate (Solu-Medrol)

d
Methylprednisolone (MP) blocks lipid peroxidation by-products and improves blood flow and reduces edema in the spinal cord. High-dose MP should be administered within 8 hours of injury. Enoxaparin is a low-molecular-weight heparin used to prevent deep vein thrombosis. Metoclopramide is used to treat delayed gastric emptying. IV immunoglobulin (Sandoglobulin) is used to treat Guillain-Barré syndrome.

A 22-year-old female with paraplegia after a spinal cord injury tells the home care nurse that bowel incontinence occurs two or three times each day. Which action by the nurse is most appropriate?

a. Take magnesium citrate (Citroma) every morning with breakfast.
b. Teach the patient to gradually increase intake of high-fiber foods.
c. Assess bowel movements for frequency, consistency, and volume.
d. Instruct the patient to avoid all caffeinated and carbonated beverages.

c
The nurse should establish baseline bowel function and explore the patient's current knowledge of an appropriate bowel management program after spinal cord injury. To prevent constipation, caffeine intake should be limited, but not eliminated. Oral saline laxatives such as magnesium citrate are not indicated for long-term management of bowel elimination. Instruction on high-fiber foods is indicated if the patient has a knowledge deficit.

The nurse is caring for a patient admitted with a spinal cord injury following a motor vehicle accident. The patient exhibits a complete loss of motor, sensory, and reflex activity below the injury level. The nurse recognizes this condition as which of the following?
Central cord syndrome
Spinal shock syndrome
Anterior cord syndrome
Brown-Séquard syndrome

Spinal shock syndrome Correct

Which clinical manifestation would the nurse interpret as a manifestation of neurogenic shock in a patient with acute spinal cord injury?
Bradycardia
Hypertension
Neurogenic spasticity
Bounding pedal pulses

Bradycardia

While on a mission trip, the nurse is caring for a patient diagnosed with tetanus. The patient has been given tetanus immune globulin (TIG). What should be the focus of collaborative care (select all that apply)?
Administration of penicillin
Tracheostomy for mechanical ventilation
Administration of polyvalent antitoxin
Teach correct processing of canned foods.
Control of spasms with diazepam (Valium)

Tracheostomy for mechanical ventilation Correct
Control of spasms with diazepam (Valium) Correct

A 25-year-old male patient who is a professional motocross racer has anterior spinal cord syndrome at T10. His history is significant for tobacco, alcohol, and marijuana use. What is the nurse's priority during rehabilitation?
Prevent urinary tract infections.
Monitor the patient every 15 minutes.
Encourage him to verbalize his feelings.
Teach him about using the gastrocolic reflex.

Encourage him to verbalize his feelings. Correct

After learning about rehabilitation for his spinal cord tumor, which statement shows the patient understands what rehabilitation is and can do for him?

"I want to be rehabilitated for my daughter's wedding in 2 weeks."

"Rehabilitation will be more work done by me alone to try to get better."

"I will be able to do all my normal activities after I go through rehabilitation."

"With rehabilitation, I will be able to function at my highest level of wellness."

"With rehabilitation, I will be able to function at my highest level of wellness."

A 42-year-old man is admitted to the hospital with a diagnosis of Guillain-Barré syndrome. The physician orders include IV Sandoglobulin. What is important for the nurse to assess for before administration?
Elevated fasting blood glucose and serum albumin
Elevated activated partial thromboplastin time (aPTT)
Elevated serum creatinine and blood urea nitrogen (BUN)
Elevated aspartate aminotransferase and alanine aminotransferase

Elevated serum creatinine and blood urea nitrogen (BUN) Correct

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A 19-year-old man is admitted to the emergency department with a C6 spinal cord injury after a motorcycle crash. Which medication should the nurse anticipate that she will administer first?
Enoxaparin (Lovenox)
Metoclopramide (Reglan)
IV immunoglobulin (Sandoglobulin)
Methylprednisolone sodium succinate (Solu-Medrol)

Methylprednisolone sodium succinate (Solu-Medrol) Correct

\

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The nurse assessing a patient with newly diagnosed trigeminal neuralgia will ask the patient about
a. visual problems caused by ptosis.
b. triggers leading to facial discomfort.
c. poor appetite caused by loss of taste.
d. weakness on the affected side of the face.

ANS: B
The major clinical manifestation of trigeminal neuralgia is severe facial pain triggered by cutaneous stimulation of the nerve. Ptosis, loss of taste, and facial weakness are not characteristics of trigeminal neuralgia.

DIF: Cognitive Level: Apply (application)

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

ANS: B
Oral hygiene is frequently neglected because of fear of triggering facial pain and may lead to gum disease, dental caries, or an abscess. Having the patient clench the facial muscles will not be useful because the sensory branches (rather than motor branches) of the nerve are affected by trigeminal neuralgia. Light touch and palpation may be triggers for pain and should be avoided.

DIF: Cognitive Level: Apply (application)

When evaluating outcomes of a glycerol rhizotomy for a patient with trigeminal neuralgia, the nurse will
a. assess if the patient is doing daily facial exercises.
b. question if the patient is using an eye shield at night.
c. ask the patient about social activities with family and friends.
d. remind the patient to chew on the unaffected side of the mouth.

ANS: C
Because withdrawal from social activities is a common manifestation of trigeminal neuralgia, asking about social activities will help in evaluating if the patient's symptoms have improved. Glycerol rhizotomy does not damage the corneal reflex or motor functions of the trigeminal nerve, so there is no need to use an eye shield, do facial exercises, or take precautions with chewing.

DIF: Cognitive Level: Apply (application)

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

ANS: A
The patient with an acute episode of trigeminal neuralgia may be unwilling to eat or drink, so assessment of nutritional and hydration status is important. Because stimulation by touch is the precipitating factor for pain, relaxation of the facial muscles will not improve symptoms. Application of ice is likely to precipitate pain. The patient will not want to engage in conversation, which may precipitate attacks.

DIF: Cognitive Level: Apply (application)

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 should the nurse include in teaching the patient?
a. "You may be able to prevent Bell's palsy by doing facial exercises regularly."
b. "Prophylactic treatment of herpes with antiviral agents prevents Bell's palsy."
c. "Medications to treat Bell's palsy work only if started before paralysis onset."
d. "Call the doctor if you experience pain or develop herpes lesions near the ear."

ANS: D
Pain or herpes lesions near the ear may indicate the onset of Bell's palsy, and rapid corticosteroid treatment may reduce the duration of Bell's palsy symptoms. Antiviral therapy for herpes simplex does not reduce the risk for Bell's palsy. Corticosteroid therapy will be most effective in reducing symptoms if started before paralysis is complete but will still be somewhat effective when started later. Facial exercises do not prevent Bell's palsy.

DIF: Cognitive Level: Apply (application)

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
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.

ANS: A
The patient's desire for privacy should be respected to encourage adequate nutrition and reduce patient embarrassment. Liquid supplements may help maintain nutrition but will reduce the patient's enjoyment of the taste of food. It would be inappropriate for the nurse to discuss the patient's embarrassment with visitors unless the patient wishes to share this information. Chewing on the unaffected side of the mouth will enhance nutrition and enjoyment of food but will not decrease the drooling.

DIF: Cognitive Level: Analyze (analysis)

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 ?
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.

ANS: C
Fecal impaction is a common stimulus for autonomic hyperreflexia. Dietary protein, coughing, and discussing sexuality and fertility should be included in the plan of care but will not reduce the risk for autonomic hyperreflexia.

DIF: Cognitive Level: Apply (application)

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

ANS: B
Drooling indicates decreased ability to swallow, which places the patient at risk for aspiration and requires rapid nursing and collaborative actions such as suctioning and possible endotracheal intubation. The foot pain should be treated with appropriate analgesics, the BP requires ongoing monitoring, and the skin integrity requires intervention, but these actions are not as urgently needed as maintenance of respiratory function.

DIF: Cognitive Level: Analyze (analysis)

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
a. infusion of immunoglobulin
b. intubation and mechanical ventilation.
c. administration of corticosteroid drugs.
d. insertion of a nasogastric (NG) feeding tube.

ANS: D
Because Guillain-Barré syndrome is in the earliest stages (as evidenced by the symptoms), use of high-dose immunoglobulin is appropriate to reduce the extent and length of symptoms. Mechanical ventilation and tube feedings may be used later in the progression of the syndrome but are not needed now. Corticosteroid use is not helpful in reducing the duration or symptoms of the syndrome.

DIF: Cognitive Level: Apply (application)

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
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.

ANS: B
If the patient has not been immunized in the past 5 years, administration of the Td booster is indicated because the wound is deep. Immune globulin administration is given by the IM route if the patient has no previous immunization. Administration of a series of immunization is not indicated. TIG is not indicated for this patient, and a test dose is not needed for immune globulin.

DIF: Cognitive Level: Apply (application)

The nurse is admitting a patient who has a neck fracture at the C6 level to the intensive care unit. Which assessment findings indicate neurogenic shock?
a. Involuntary and spastic movement
b. Hypotension and warm extremities
c. Hyperactive reflexes below the injury
d. Lack of sensation or movement below the injury

ANS: B
Neurogenic shock is characterized by hypotension, bradycardia, and vasodilation leading to warm skin temperature. Spasticity and hyperactive reflexes do not occur at this stage of spinal cord injury. Lack of movement and sensation indicate spinal cord injury but not neurogenic shock.

DIF: Cognitive Level: Understand (comprehension)

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?
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

ANS: C
The patient with Brown-Séquard syndrome has loss of motor function on the ipsilateral side and will require the nurse to move the left leg. Pain sensation will be lost in the patient's right leg. Arm weakness will not be a problem for a patient with a T7 injury. The patient will retain position sense for the right leg.

DIF: Cognitive Level: Apply (application)

The nurse will explain to the patient who has a T2 spinal cord transection injury that
a. use of the shoulders will be limited.
b. function of both arms should be retained.
c. total loss of respiratory function may occur.
d. tachycardia is common with this type of injury.

ANS: B
The patient with a T2 injury can expect to retain full motor and sensory function of the arms. Use of only the shoulders is associated with cervical spine injury. Loss of respiratory function occurs with cervical spine injuries. Bradycardia is associated with injuries above the T6 level.

DIF: Cognitive Level: Understand (comprehension)

A patient with paraplegia resulting from a T9 spinal cord injury has a neurogenic reflexic bladder. Which action will the nurse include in the plan of care?
a. Teach the patient the Credé method.
b. Instruct the patient how to self-catheterize.
c. Catheterize for residual urine after voiding.
d. Assist the patient to the toilet every 2 hours.

ANS: B
Because the patient's bladder is spastic and will empty in response to overstretching of the bladder wall, the most appropriate method is to avoid incontinence by emptying the bladder at regular intervals through intermittent catheterization. Assisting the patient to the toilet will not be helpful because the bladder will not empty. The Credé method is more appropriate for a bladder that is flaccid, such as occurs with areflexic neurogenic bladder. Catheterization after voiding will not resolve the patient's incontinence.

DIF: Cognitive Level: Apply (application)

When the nurse is developing a rehabilitation plan for a 30-yr-old patient with a C6 spinal cord injury, an appropriate goal is that the patient will be able to
a. drive a car with powered hand controls.
b. push a manual wheelchair on a flat surface.
c. turn and reposition independently when in bed.
d. transfer independently to and from a wheelchair.

ANS: B
The patient with a C6 injury will be able to use the hands to push a wheelchair on flat, smooth surfaces. Because flexion of the thumb and fingers is minimal, the patient will not be able to grasp a wheelchair during transfer, drive a car with powered hand controls, or turn independently in bed.

DIF: Cognitive Level: Apply (application)

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?
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.

ANS: B
The patient is demonstrating behaviors consistent with the anger phase of the grief process, and the nurse should allow expression of anger and seek the patient's input into care. Expression of anger is appropriate at this stage, and should be accepted by the nurse. Reassurance about the competency of the staff will not be helpful in responding to the patient's concerns. Ignoring the patient's comments will increase the patient's anger and sense of helplessness.

DIF: Cognitive Level: Apply (application)

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
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.

ANS: C
The best action by the nurse will be to involve all parties in developing an optimal plan of care. Because family members who will be assisting with the patient's ongoing care need to believe their input is important, telling the spouse that the patient can perform activities independently is not the best choice. Reminding the patient about the importance of independence may not change the behaviors of the spouse. Supporting the activities of the spouse will lead to ongoing dependency by the patient.

DIF: Cognitive Level: Apply (application)