Question 1

Which of the following nursing actions should the home health nurse include in the plan of care for a client with paraplegia in order to prevent autonomic dysreflexia?

Accepted Answer

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.

Question 2

After a young adult client has returned home following rehabilitation for a spinal cord injury, the home care nurse notes that the partner is performing many of the activities that the client had been managing during rehabilitation. Which of the followingactions by the nurse is most appropriate at this time?

Accepted Answer

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 client's ongoing care need to feel that their input is important, telling the spouse that the client can perform activities independently is not the best choice. Reminding the client about the importance of independence may not change the behaviours of the spouse. Supporting the activities of the spouse will lead to ongoing dependency by the client.

Question 3

The nurse is caring for a client with a neck fracture at the C5 level in the intensive care unit. During initial assessment of the client, the nurse recognizes the presence of neurogenic shock upon assessing which of the following findings?

Accepted Answer

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 or sensation indicates spinal cord injury, but not neurogenic shock.

Question 4

A client arrives at an urgent care centre with a deep puncture wound after stepping on a nail that was lying on the ground. The client reports having had a tetanus booster 7 years ago. Which of the following actions should the nurse anticipate?

Accepted Answer

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

Question 5

The nurse is caring for a client who has Guillain-Barré syndrome. Which of the following assessment data obtained by the nurse will require the most immediate action?

Accepted Answer

Drooling indicates decreased ability to swallow, which places the client 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, and the BP requires ongoing monitoring, but these actions are not as urgently needed as maintenance of respiratory function. Absence of the reflexes should be documented, but this is a common finding in Guillain-Barré syndrome.

Question 6

The nurse is caring for a client with trigeminal neuralgia who has had a glycerol rhizotomy. Which of the following interventions should the nurse implement?

Accepted Answer

Because withdrawal from social activities is a common manifestation of trigeminal neuralgia, asking about social activities will help in evaluating whether the client'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.

Question 7

The nurse is assessing a client with newly diagnosed trigeminal neuralgia. Which of the following parameters should the nurse assess?

Accepted Answer

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

Question 8

The nurse is teaching a client who is at risk for Bell's palsy because of previous herpes simplex infection. Which of the following information should the nurse include?

Accepted Answer

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.

Question 9

The nurse is caring for a client who has numbness and weakness of both feet and who is hospitalized with Guillain-Barré syndrome. Which of the following information should the nurse include in the client's plan of care?

Accepted Answer

Because the 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.

Question 10

The nurse is caring for a client who has onset Guillain-Barré syndrome. During this phase of the client's illness, which of the following parameters is the most important for the nurse to assess?

Accepted Answer

The most serious complication of Guillain-Barré syndrome is respiratory failure, and the nurse should monitor respiratory function continuously. The other assessments also will be included in nursing care, but they are not as important as respiratory assessment.

Question 11

The nurse is developing a rehabilitation plan for a client with a C6 spinal cord injury. Which of the following goals should the nurse include for this client?

Accepted Answer

The client 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 client will not be able to grasp a wheelchair during transfer, drive a car with powered hand controls, or turn independently in bed.

Question 12

The nurse is caring for a client with paraplegia resulting from a T10 spinal cord injury who has a neurogenic reflex bladder. Which of the following actions should the nurse include in the plan of care?

Accepted Answer

Because the client'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 client 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 client's incontinence.

Question 13

The nurse is caring for a client with a T1 spinal cord injury in the intensive care unit. Which of the following information should the nurse include in the teaching plan for the client and family?

Accepted Answer

The client 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.

Question 14

The nurse is caring for a client who was admitted 24 hours previously with a C5 spinal cord injury. Which of the following nursing actions has the highest priority?

Accepted Answer

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

Question 15

Which of the following actions should the nurse include in the plan of care when caring for a client who is experiencing trigeminal neuralgia?

Accepted Answer

The client 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 client will not want to engage in conversation, which may precipitate attacks.

Question 16

The nurse is caring for a client who sustained a spinal cord injury a week ago and becomes angry, telling the nurse "I want to be transferred to a hospital where the nurses know what they are doing!" Which of the following actions by the nurse is best?

Accepted Answer

The client is demonstrating behaviours consistent with the anger phase of the mourning process, and the nurse should allow expression of anger and seek the client'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 client's anger. Ignoring the client's comments will increase the client's anger and sense of helplessness.

Question 17

The health care provider prescribes these interventions for a client with possible botulism poisoning. Which of the following prescriptions should the nurse question?

Accepted Answer

Magnesium is contraindicated because it may worsen the neuro-muscular blockade. The other orders are appropriate for the client.

Question 18

Which of the following actions should the nurse take when assessing a client with trigeminal neuralgia?

Accepted Answer

Oral hygiene is frequently neglected because of fear of triggering facial pain. Having the client clench the facial muscles will not be useful because the sensory branches of the nerve are affected by trigeminal neuralgia. Light touch and palpation may be triggers for pain and should be avoided.

Question 19

The nurse is caring for a client who has an incomplete right spinal cord lesion at the level of T7, resulting in Brown-Séquard syndrome. Which of the following nursing actions should be included in the plan of care?

Accepted Answer

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

Question 20

The nurse is caring for a client with Bell's palsy who refuses to eat while others are present because of embarrassment about drooling. Which of the following responses is best for the nurse to do?

Accepted Answer

The client's desire for privacy should be respected to encourage adequate nutrition and reduce client embarrassment. Liquid supplements will reduce the client's enjoyment of the taste of food. It would be inappropriate for the nurse to discuss the client's embarrassment with visitors unless the client 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.

Quiz 63: Nursing Management Peripheral Nerve and Spinal Cord Problems