Chapter 60 Spinal Cord and Peripheral Nerve Problems PDF

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TestBank-Medical-SurgicalNursing:AssessmentandManagementofClinicalProblems10e

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Chapter60:SpinalCordandPeripheralNerveProblems TestBank MULTIPLECHOICE 1.Thenurseassessinga54-year-oldfemale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thatis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)REF:1420 TOP:NursingProcess:AssessmentMSC:NCLEX:PhysiologicalIntegrity 2.Whichactionshouldthenursetakewhenassessingapatientwith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.Havingthepatient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. DIF:CognitiveLevel:Apply(application)REF:1421 TOP:NursingProcess:AssessmentMSC:NCLEX:PhysiologicalIntegrity 3.Whenevaluatingoutcomesofaglycerolrhizotomyforapatientwithtrigeminalneuralgia,thenursewill a.

assesswhetherthepatientisdoingdailyfacialexercises.

TestBank-Medical-SurgicalNursing:AssessmentandManagementofClinicalProblems10e

b.

questionwhether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.

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ANS:C Becausewithdrawalfromsocialactivitiesisacommonmanifestationoftrigeminalneuralgia,askingabout socialactivitieswillhelpinevaluatingwhetherthepatients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)REF:1420 TOP:NursingProcess:EvaluationMSC:NCLEX:PhysiologicalIntegrity 4.Whichactionwillthenurseincludeintheplanofcarefora62-year-old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)REF:1420 TOP:NursingProcess:PlanningMSC:NCLEX:PhysiologicalIntegrity 5.Thenurseidentifiesapatientwithtype1diabetesandahistoryofherpessimplexinfectionasbeingatrisk forBellspalsy.Whichinformationshouldthenurseincludeinteachingthepatient? a.

YoumaybeabletopreventBellspalsybydoingfacialexercisesregularly.

b.

ProphylactictreatmentofherpeswithantiviralagentspreventsBellspalsy.

c.

MedicationstotreatBellspalsyworkonlyifstartedbeforeparalysisonset.

d.

Callthedoctorifyouexperiencepainordevelopherpeslesionsneartheear.

TestBank-Medical-SurgicalNursing:AssessmentandManagementofClinicalProblems10e

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ANS:D PainorherpeslesionsneartheearmayindicatetheonsetofBellspalsyandrapidcorticosteroidtreatmentmay reducethedurationofBellspalsysymptoms.Antiviraltherapyforherpessimplexdoesnotreducetheriskfor Bells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Bellspalsy. DIF:CognitiveLevel:Apply(application)REF:1422 TOP:NursingProcess:ImplementationMSC:NCLEX:PhysiologicalIntegrity 6.A32-year-oldpregnantpatientwithBellspalsyrefusestoeatwhileothersarepresentbecauseof embarrassmentaboutdrooling.Thebestresponsebythenurseisto a.

respectthepatients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patientsconcernswithvisitorswhoarriveatmealtimes.

ANS:A Thepatientsdesireforprivacyshouldberespectedtoencourageadequatenutritionandreducepatient embarrassment.Liquidsupplementswillreducethepatientsenjoymentofthetasteoffood.Itwouldbe inappropriateforthenursetodiscussthepatients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:Apply(application)REF:1423 TOP:NursingProcess:ImplementationMSC:NCLEX:PsychosocialIntegrity 7.Whichnursingactionwillthehomehealthnurseincludeintheplanofcareforapatientwithparaplegiaat theT4levelinordertopreventautonomicdysreflexia? 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dysreflexia.Dietaryprotein,coughing,anddiscussing sexuality/fertilityshouldbeincludedintheplanofcarebutwillnotreducetheriskforautonomicdysreflexia. DIF:CognitiveLevel:Apply(application)REF:1435

TestBank-Medical-SurgicalNursing:AssessmentandManagementofClinicalProblems10e

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TOP:NursingProcess:PlanningMSC:NCLEX:PhysiologicalIntegrity 8.WhichassessmentdataforapatientwhohasGuillain-Barrsyndromewillrequirethenursesmost immediateaction? a.

Thepatientstricepsreflexesareabsent.

b.

Thepatientiscontinuouslydroolingsaliva.

c.

Thepatientcomplainsofseverepaininthefeet.

d.

Thepatients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,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-Barrsyndrome. DIF:CognitiveLevel:Apply(application)REF:1424 OBJ:SpecialQuestions:PrioritizationTOP:NursingProcess:Assessment MSC:NCLEX:PhysiologicalIntegrity 9.A68-year-oldpatienthospitalizedwithanewdiagnosisofGuillain-Barrsyndromehasnumbnessand weaknessofbothfeet.Thenursewillanticipateteachingthepatientabout a.

intubationandmechanicalventilation.

b.

administrationofcorticosteroiddrugs.

c.

insertionofanasogastric(NG)feedingtube.

d.

infusionofimmunoglobulin(Sandoglobulin).

ANS:D BecausetheGuillain-Barr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)REF:1423 TOP:NursingProcess:ImplementationMSC:NCLEX:PhysiologicalIntegrity 10.Aconstructionworkerarrivesatanurgentcarecenterwithadeeppuncturewoundafteranoldnail penetratedhisboot..Thepatientreportshavinghadatetanusbooster6yearsago.Thenursewillanticipate

TestBank-Medical-SurgicalNursing:AssessmentandManagementofClinicalProblems10e

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.

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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. DIF:CognitiveLevel:Apply(application)REF:1424 TOP:NursingProcess:ImplementationMSC:NCLEX:PhysiologicalIntegrity 11.ThenurseisadmittingapatientwithaneckfractureattheC6leveltotheintensivecareunit.Which assessmentfinding(s)indicate(s)neurogenicshock? a.

Hyperactivereflexactivitybelowthelevelofinjury

b.

Involuntary,spasticmovementsofthearmsandlegs

c.

Hypotension,bradycardia,andwarm,pinkextremities

d.

Lackofsensationormovementbelowthelevelofinjury

ANS:C 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)REF:1426 TOP:NursingProcess:AssessmentMSC:NCLEX:PhysiologicalIntegrity 12.ApatienthasanincompleteleftspinalcordlesionatthelevelofT7,resultinginBrown-Squard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patientsleftlegwhenturningthepatient

d.

Teachingthepatienttolookattherightlegtoverifyitsposition

TestBank-Medical-SurgicalNursing:AssessmentandManagementofClinicalProblems10e

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ANS:C ThepatientwithBrown-Squard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onthepatients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)REF:1428 TOP:NursingProcess:ImplementationMSC:NCLEX:PhysiologicalIntegrity 13.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)REF:1429 TOP:NursingProcess:ImplementationMSC:NCLEX:PhysiologicalIntegrity 14.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Cred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patients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Credmethodismoreappropriateforabladderthatisflaccid,suchasoccurswithareflexic neurogenicbladder.Catheterizationaftervoidingwillnotresolvethepatientsincontinence. DIF:CognitiveLevel:Apply(application)REF:1437

TestBank-Medical-SurgicalNursing:AssessmentandManagementofClinicalProblems10e

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TOP:NursingProcess:PlanningMSC:NCLEX:PhysiologicalIntegrity 15.Whenthenurseisdevelopingarehabilitationplanfora30-year-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)REF:1429 TOP:NursingProcess:PlanningMSC:NCLEX:PhysiologicalIntegrity 16.A20-year-oldpatientwhosustainedaT2spinalcordinjury10daysagoangrily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best? a.

Clarify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patients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patients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patientsanger.Ignoringthepatientscommentswillincreasethepatientsangerand senseofhelplessness. DIF:CognitiveLevel:Apply(application)REF:1439 TOP:NursingProcess:ImplementationMSC:NCLEX:PsychosocialIntegrity 17.A38-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unassisted duringrehabilitation.Themostappropriateactionbythenurseatthistimeisto a.

remindthepatientabouttheimportanceofindependenceindailyactivities.

TestBank-Medical-SurgicalNursing:AssessmentandManagementofClinicalProblems10e

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b.

tellthespousetostopbecausethepatientisabletoperformactivitiesindependently.

c.

developaplantoincreasethepatientsindependenceinconsultationwiththepatientandthe spouse.

d.

recognizethatitisimportantforthespousetobeinvolvedinthepatientscareandencouragethat 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patients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. DIF:CognitiveLevel:Apply(application)REF:1440 TOP:NursingProcess:ImplementationMSC:NCLEX:PsychosocialIntegrity 18.Apatientisadmittedwithpossiblebotulismpoisoningaftereatinghome-cannedgreenbeans.Which interventionorderedbyhealthcareproviderwillthenursequestion? a.

Encourageoralfluidsto3L/day

b.

Documentneurologicsymptoms

c.

Positionpatientlyingontheside

d.

Observerespiratorystatusclosely

ANS:A ThepatientshouldbemaintainedonNPOstatusbecauseneuromuscularweaknessincreasesriskforaspiration Side-lyingpositionisnotcontraindicated.Assessmentofneurologicandrespiratorystatusisappropriate. DIF:CognitiveLevel:Apply(application)REF:1424 TOP:NursingProcess:ImplementationMSC:NCLEX:PhysiologicalIntegrity 19.Whichnursingactionhasthehighestpriorityforapatientwhowasadmitted16hourspreviouslywithaC5 spinalcordinjury? a.

Cardiacmonitoringforbradycardia

b.

Assessmentofrespiratoryrateandeffort

c.

Applicationofpneumaticcompressiondevicestolegs

d.

Administrationofmethylprednisolone(Solu-Medrol)infusion

TestBank-Medical-SurgicalNursing:AssessmentandManagementofClinicalProblems10e

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ANS:B EdemaaroundtheareaofinjurymayleadtodamageabovetheC4level,sothehighestpriorityisassessment ofthepatientsrespiratoryfunction.Methylprednisolone(Solu-Medrol)isnolongerrecommendedforthe treatmentofspinalcordinjuries.Theotheractionsalsoareappropriatebutarenotasimportantasassessment ofrespiratoryeffort. DIF:CognitiveLevel:Apply(application)REF:1433 OBJ:SpecialQuestions:PrioritizationTOP:NursingProcess:Assessment MSC:NCLEX:PhysiologicalIntegrity 20.A27-year-oldpatientishospitalizedwithnewonsetofGuillain-Barrsyndrome.Themostessential assessmentforthenursetocarryoutis a.

determininglevelofconsciousness.

b.

checkingstrengthoftheextremities.

c.

observingrespiratoryrateandeffort.

d.

monitoringthecardiacrateandrhythm.

ANS:C ThemostseriouscomplicationofGuillain-Barrsyndromeisrespir...