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The client with epilepsy develops stiffening of the muscles of the arms and legs, followed by an immediate loss of consciousness and jerking of all extremities. How will the nurse document this seizure activity?
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a.Generalized atonic seizure
- b.Generalized absence seizure
- c.Generalized myoclonic seizure
- d.Generalized tonic-clonic seizure
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ANS:D
Seizure activity that begins with a stiffening of the arms and legs, followed by a loss of consciousness and jerking of all extremities, is characteristic of a tonic-clonic seizure.
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For which clinical manifestation in the client with a history of complex partial seizures will the nurse assess?
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a.Automatisms
- b.Blank staring
- c.Sudden loss of muscle tone
- d.Brief jerking of the extremities
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ANS:A
Automatisms are characteristic of partial seizures. These behaviors consist of lip smacking, patting, and picking at clothing.
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A nurse is caring for a client with a history of epilepsy who suddenly begins to experience a tonic-clonic seizure and loses consciousness. Which is the nurse�s priority action?
- a. Restraining the client�s extremities
- b. Turning the client�s head to the side
- c. Taking the client�s blood pressure
- d. Placing an airway into the client�s mouth
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ANS: B
The nurse should turn the client�s head to the side to prevent aspiration and allow drainage of secretions. The client should not be restrained nor an airway placed in his or her mouth during the seizure because these actions increase seizure activity and can harm the client. Vital signs are measured in the postictal phase of the seizure.
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The client is prescribed phenytoin (Dilantin) for treatment of a seizure disorder. Which precaution or instruction will be taught to this client?
- a. �Do not take aspirin or aspirin-containing products while on this medication.�
- b. �Avoid contact sports and heavy physical exercise while on this medication.�
- c. �Avoid direct exposure to sunlight while on this medication.�
- d. �Do not take warfarin (Coumadin) while on this medication.�
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ANS: D
Warfarin inhibits the metabolism of phenytoin, increasing the half-life of phenytoin and the risk of development of toxic levels.
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Which statement made by a client with newly diagnosed epilepsy indicates that further teaching concerning the drug regimen is necessary?
- a. �I will avoid alcohol.�
- b. �I will wear a medical alert bracelet.�
- c. �I will let my doctor know about this drug when I receive a new prescription for other conditions.�
- d. �I can miss up to two pills if I run out of them or they make me ill.�
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ANS: D
The nurse needs to emphasize that antiepileptic drugs must be taken even if seizure activity has stopped. Discontinuing the medication can predispose the client to seizure activity and status epilepticus.
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Which precautions will the nurse institute to ensure the safety of a client with epilepsy who has been hospitalized? (Select all that apply.)
- a. Have suction equipment at the bedside.
- b. Place a padded tongue at bedside.
- c. Permit only clear oral fluids.
- d. Keep bed rails up at all times.
- e. Maintain the client on strict bedrest.
- f. Ensure that the client has IV access.
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ANS: A, D, F
The bed rails should be up at all times while the client is in the bed to prevent an injury from a fall if the client has a seizure. Padded tongue blades may pose a danger to the client during a seizure. Be sure that oxygen and suctioning equipment with an airway are readily available. If the client does not have an IV access, insert a saline lock, especially for those clients who are at significant risk for generalized tonic-clonic seizures. The saline lock provides ready access if IV drug therapy must be given to stop the seizure.
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A nurse is caring for a client experiencing spinal shock after a spinal cord injury. Which clinical manifestation indicates the resolution of spinal shock?
- a. The return of reflex activity
- b. Normalization of the pupillary reflex
- c. Return of bowel and bladder continence
- d. Tingling in the extremities below the lesion
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ANS: A
The resolution of spinal shock is signaled by the return of reflex activity. Note that spinal shock and neurogenic shock are not interchangeable terms and describe different pathologic phenomena.
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A client who suffered a spinal cord injury at level T5 several months ago develops a flushed face and blurred vision. On taking vital signs, the nurse notes the blood pressure to be 184/95 mm Hg. Which is the nurse�s first action?
- a. Palpating the area over the bladder for distention
- b. Placing the client in the Trendelenburg position
- c. Administering oxygen via a nasal cannula
- d. Performing carotid massage
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ANS: A
The client is manifesting symptoms of autonomic dysreflexia. Common causes include bladder distention, tight clothing, increased room temperature, and fecal impaction. If persistent, the client could experience neurologic injury. Precipitating conditions should be eliminated and the physician notified.
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A client has arrived by ambulance at the emergency department after a cervical spinal cord injury. Which assessment is a priority for the nurse to perform at this time?
- a. Mental status
- b. Heart rate and rhythm
- c. Muscle strength and reflexes
- d. Respiratory pattern and airway
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ANS: D
The first priority for a client with a spinal cord injury is assessment of respiratory status and airway patency. Clients with cervical spine injuries are particularly prone to respiratory compromise and may even require intubation. Priority nursing diagnoses include Ineffective Airway Clearance, Ineffective Breathing Pattern, and Impaired Gas Exchange.
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Which technique will the nurse use to assess proprioceptive function of the lower extremities in a client with a suspected spinal cord injury?
- a. Asking the client to flex and extend the feet and knees
- b. With the client�s eyes closed, moving the client�s toe up or down
- c. Applying resistance while the client plantar flexes the legs and feet
- d. Applying pinprick to the lower extremities and comparing bilaterally
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ANS: B
The proper technique for testing proprioception is to ask the client to close his or her eyes. Move the client�s toe up or down and ask him or her to identify the position of the digit.
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The nurse monitors for which complication in the client with an incomplete upper motor neuron lesion?
- a. Contractures
- b. Hyperreflexia
- c. Hypotension
- d. Visual disturbances
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ANS: A
Individuals with upper motor neuron lesions have muscle spasticity that can lead to contractures once spinal shock has resolved.
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Within 4 hours of a cervical spinal injury, the client can discriminate light touch and position of the arms but cannot perform any motor function. What is the nurse�s interpretation of this finding?
- a. Lateral spinal cord injury
- b. Central spinal cord injury
- c. Posterior spinal cord injury
- d. Anterior spinal cord injury
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ANS: D
With a spinal cord injury to the anterior portion of the cervical spine, the client may retain some sensory function (touch, vibration, and position are in the posterior portion) but may not have motor function and pain and temperature sensation. Whether the injury is permanent or temporary cannot be ascertained at this time.
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Which nursing diagnoses is a priority for the client with autonomic dysreflexia?
- a. Impaired Adjustment related to depression
- b. Self-care Deficit related to spinal cord injury
- c. Impaired Physical Mobility related to paraplegia
- d. Impaired Urinary Elimination related to neurogenic bladder
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ANS: D
For clients with spinal shock, autonomic dysfunction causes an areflexic bladder, leading to urinary retention and neurogenic bladder.
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A nurse is assessing deep tendon reflexes in a client who sustained a spinal cord injury 5 days ago. The nurse can elicit a mild response to a tap on the patella. Which is the nurse�s interpretation of this finding?
- a. There is a gradual response of all the nerves and muscles.
- b. It is too early to tell how extensive the injury is at this time.
- c. The injury has resulted in only temporary spinal cord dysfunction.
- d. The spinal shock phase of the injury is over.
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ANS: D
The patellar reflex is an ipsilateral response of lower motor neurons. It can remain intact even when the spinal cord is completely severed because this reflex does not require input from upper motor neurons or interneurons. Return of reflexes is a sign of spinal shock resolution. Note that spinal shock is not neurogenic shock.
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Which intervention is most likely to achieve the expected outcome of preventing deterioration in neurologic status in a client with a vertebral fracture?
- a. Reorienting the client to time, place, and person, as needed
- b. Administering the Mini-Mental State Examination
- c. Immobilizing the affected portion of the spinal column
- d. Repositioning the client every 2 hours
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ANS: C
The nurse keeps the client in optimal body alignment at all times, avoiding flexion and extension at the site of vertebral injury, to prevent further cord injury or irritability from bone fragments. A brace, traction, or external fixation may be used for this purpose
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A client who experienced a spinal cord injury 1 hour ago is brought to the emergency room. Which medication will the nurse prepare to administer to this client?
- a. Intrathecal baclofen
- b. Methylprednisolone
- c. Atropine sulfate
- d. Epinephrine
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ANS: B
Methylprednisolone (Solu-Medrol) should be given within 8 hours of the injury. Clients receiving this therapy usually show improvement in motor and sensory function.
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Which symptom(s) experienced by a client with a spinal cord injury at the T5 level would alert the nurse to the presence of a complication of this injury?
- a. Rhinorrhea
- b. Fever and cough
- c. Anxiety and restlessness
- d. Pain radiating from the hip to the knee
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ANS: B
Clients with injuries at or above the T6 vertebra are especially at risk for respiratory complications caused by impaired intercostal muscles. The development of fever and cough should alert the nurse to the possibility of pneumonia.
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A nurse notes reddened areas over the hips and sacrum of a client with paraplegia from a spinal cord injury. Which is the nurse�s best action?
- a. Rubbing the areas with an oil-based lubricant
- b. Performing hip flexion and extension range-of-motion (ROM) exercises
- c. Repositioning the client so that the reddened area does not bear weight
- d. Ensuring that the client sits in a chair at least once each shift
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ANS: C
The reddened areas should not be rubbed, because this action could cause more extensive damage to the already fragile capillary system. ROM exercises are used to prevent contractures. The reddened areas should be assessed for blanching. If the skin does not blanch, the area is vulnerable to breakdown. Appropriate interventions to relieve the pressure on these areas through positioning, assistive devices, and skin protection should then be used.
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A nurse is caring for a client with an upper motor neuron lesion who wishes to achieve bladder control. Which intervention is most likely to be effective in stimulating initiation of voiding for this client?
- a. Stroking the inner aspect of the thigh
- b. Using intermittent catheterization
- c. Providing digital anal stimulation
- d. Using the Valsalva maneuver
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The client has experienced a lower motor neuron injury and as a result has a flaccid bowel elimination pattern, with infrequent passage of hard, dry stool. The nurse implements which action to assist in relieving this client�s constipation?
- a. Pouring warm water over the perineum
- b. Tapping the abdomen from left to right
- c. Daily tap water enemas
- d. Manual disimpaction
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ANS: D
For the client with a lower motor neuron injury, the resulting flaccid bowel may require the client to be manually disimpacted. Scheduled toileting and massaging the abdomen from right to left also may be helpful.
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A client complains of a tight, band-like feeling around the trunk and sensations of numbness and tingling in both legs after a motor vehicle crash. Which is the nurse�s priority action?
- a. Immobilizing the client and notifying the physician
- b. Medicating the client for pain and providing oxygen
- c. Assessing proprioception while massaging both legs
- d. Performing ROM exercises on the extremities
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ANS: A
The client is demonstrating symptoms of spinal cord compression. Prompt treatment is necessary to prevent paralysis and loss of function.
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The nurse correlates which pathophysiologic process to the client with a diagnosis of multiple sclerosis (MS)?
- a. Poor cellular repair mechanisms support the proliferation of dysfunctional neurons.
- b. The autoimmune response causes damage to unmyelinated nerve fibers.
- c. Degeneration of axonal bodies interferes with signal transmission.
- d. Damage to the myelin sheath causes an inflammatory response.
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ANS: D
In MS, the myelin sheath is damaged, leading to an inflammatory response.
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The nurse assesses for which clinical manifestation in the client with MS of the relapsing-remitting type?
- a. Absence of periods of remission
- b. Attacks becoming increasingly frequent
- c. Absence of active disease manifestations
- d. Gradual neurologic symptoms without remission
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ANS: B
The classic picture of relapsing-remitting MS is characterized by increasingly frequent attacks.
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Which clinical manifestations would serve to alert the nurse to the early onset of MS?
- a. Hyperresponsive reflexes
- b. Excessive somnolence
- c. Nystagmus and ataxia
- d. Heat intolerance
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ANS: C
Early signs and symptoms of MS include changes in motor skills, vision, and sensation.
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A client presents with an acute exacerbation of multiple sclerosis. Which drug will the nurse be prepared to administer?
- a. Baclofen (Lioresal)
- b. Interferon beta-1b (Betaseron)
- c. Dantrolene sodium (Dantrium)
- d. Methylprednisolone (Medrol)
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ANS: D
Methylprednisolone is the drug of choice for acute exacerbations of the disease.
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The client with relapsing-remitting multiple sclerosis asks why continuous treatment with interferon beta-1a (Avonex) is necessary. Which is the nurse�s best response?
- a. �This medication will help decrease the number and severity of relapses.�
- b. �This medication is given weekly to halt progression of the disease.�
- c. �This medication is given continuously for 1 year to produce a cure.�
- d. �This medication will protect your muscles from spasticity.�
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ANS: A
Interferon beta-1a is a biologic response modifier that is given IM once weekly to decrease the number and severity of relapses
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A client with multiple sclerosis has been treated for 6 months with mitoxantrone (Novantrone). Which clinical manifestation alerts the nurse to an adverse effect of this medication?
- a. Periorbital edema
- b. Black tarry stools
- c. Crackles in the lungs
- d. Nausea and vomiting after meals
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ANS: C
Mitoxantrone (Novantrone) is an antineoplastic agent that can cause cardiotoxicity when used for long periods. Adverse effects are congestive heart failure and dysrhythmias.
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A nurse is preparing a client newly diagnosed with multiple sclerosis for discharge home from a rehabilitation center. The client has been prescribed cyclophosphamide (Cytoxan) and methylprednisolone (Medrol). Which instruction will the nurse include in a teaching plan for the client?
- a. �Take hot baths.�
- b. �Avoid people with colds.�
- c. �Try to use physical aids such as walkers as little as possible.�
- d. �You may discontinue these medications when your symptoms improve.�
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ANS: B
The client should be taught to avoid individuals with any type of upper respiratory illness because these medications are immunosuppressive.
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Which neurologic test or procedure requires the nurse to determine whether an informed consent has been obtained from the client before the test or procedure?
- a. Measurement of sensation using the pinprick method
- b. Computerized tomography of the cranial vault
- c. Lumbar puncture for cerebrospinal fluid (CSF) sampling
- d. Venipuncture for autoantibody analysis
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ANS: C
A lumbar puncture is an invasive procedure with many potentially serious complications. The other assessments or tests are considered noninvasive.
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The client is scheduled to have central nervous system magnetic resonance imaging (MRI). Which nursing intervention is most appropriate in preparation for this procedure?
- a. Ensuring that the person does not eat for 6 to 8 hours before the procedure
- b. Discontinuing all neuroactive medications and foods 3 to 4 hours before the procedure
- c. Making sure that the client has an identifier that cannot be removed
- d. Replacing the gown with metal snaps with one that has cloth ties
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ANS: D
Metal objects are a hazard because of the magnetic field used in the MRI procedure.
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Which is the priority teaching focus for the client with an unstable thoracic vertebral fracture that is being treated with immobilization prior to surgery?
- a. Ensure that the client knows how to apply the immobilizing brace snugly around the trunk.
- b. Remind him or her to lie immobile on the backboard used to transport injured clients from the field to the hospital.
- c. Explain that it is important that the trunk remain in alignment. Avoid sitting up, arching the back, or twisting to either side.
- d. Teach the client to cough and breathe deeply to avoid postoperative complications of atelectasis and pneumonia.
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ANS: C
The client with a thoracic vertebral fracture is at risk for spinal cord injury, especially with flexion, extension, or rotation of the trunk.
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Which conditions or factors in an adult woman diagnosed with MS are most likely to have contributed to this health problem?
- a. Dietary factors such as high-fat or high-calorie intake
- b. Heritability or genetic factors
- c. Daily intake of aspirin or other nonsteroidal anti-inflammatory drugs (NSAIDs)
- d. Sedentary lifestyle
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ANS: B
Having a first-degree relative with MS increases the individual�s risk of developing the disease. There is a higher prevalence of certain genes in populations with higher rates of MS.
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Which statement by the male client with a spinal cord injury at T4 (thoracic) indicates the need for further teaching?
- a. �I will not be able to have an erection because of my injury.�
- b. �Ejaculation may not be predictable as before.�
- c. �I may urinate with ejaculation.�
- d. �I should be able to have an erection with stimulation.�
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ANS: A
Men with injuries above T6 are often able to have erections by stimulating reflex activity. For example, stroking the penis will cause an erection. Ejaculation is less predictable, and may be mixed with urine. However, urine is sterile, so the client�s partner will not get an infection.
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The nurse collaborates most closely with which health care discipline in providing adaptive equipment to assist with activities of daily living in the client with a spinal cord injury?
- a. Social worker
- b. Physical therapist
- c. Occupational therapist
- d. Case manager
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ANS: C
The occupational therapist instructs the client in the correct use of all adaptive equipment. In collaboration with the therapists, instruct family members or the caregiver about transfer skills, feeding, bathing, dressing, positioning, and skin care.
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The nurse monitors for which clinical manifestations in the client with a transection at C4 (cervical)? (Select all that apply.)
- a. Elbow extension and flexion
- b. Ipsilateral motor loss with contralateral loss of sensation
- c. Ability to control the mouth and head
- d. Intact rapid finger movement
- e. Loss of sensation in fingers
- f. Loss of all respiratory function
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ANS: C, E
C4 and C7 transections are complete injuries, with paralysis and loss of sensation below the injury and preserved sensorimotor control above the injury.
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In assessing the client�s coping strategies after suffering a traumatic spinal cord injury, it is important for the nurse to obtain which information? (Select all that apply.)
- a. Spiritual or religious beliefs
- b. Level of pain
- c. Family support
- d. Level of independence
- e. Annual income
- f. Prior coping strategies
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A patient with Guillain-Barr� syndrome asks the nurse what has caused the disease. In responding to the patient, the nurse explains that Guillain-Barr� syndrome
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a. results from an acute infection and inflammation of the peripheral nerves.
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b. is due to an immune reaction that attacks the covering of the peripheral nerves.
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c. is caused by destruction of the peripheral nerves after exposure to a viral infection.
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d. results from degeneration of the peripheral nerve caused by viral attacks.
ANS: B Guillain-Barr� syndrome is believed to result from an immunologic reaction that damages the myelin sheath of the peripheral nerves. Acute infection or inflammation of the nerves is not a cause. The peripheral nerves are not destroyed and do not degenerate.
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A 24-year-old patient is hospitalized with the onset of Guillain-Barr� syndrome. During this phase of the patient�s illness, the most essential assessment for the nurse to carry out is
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a. monitoring the cardiac rhythm continuously.
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b. termining the level of consciousness q2hr.
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c. evaluating sensation and strength of the extremities.
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d. performing constant evaluation of respiratory function.
ANS: D The most serious complication of Guillain-Barr� syndrome is respiratory failure, and the nurse should monitor respiratory function continuously. The other assessments will also be included in nursing care, but they are not as important as respiratory assessment.
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When caring for a patient who has Guillain-Barr� syndrome, which assessment data obtained by the nurse will require the most immediate action?
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a. The patient complains of severe tingling pain in the feet.
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b. The patient has continuous drooling of saliva.
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c. The patient�s blood pressure (BP) is 106/50 mm Hg.
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d. The patient�s quadriceps and triceps reflexes are absent.
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
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A patient who has numbness and weakness of both feet is hospitalized with Guillain-Barr� syndrome. The nurse will anticipate that collaborative interventions at this time will include
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a. intubation and mechanical ventilation.
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b. insertion of a nasogastric (NG) feeding tube.
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c. administration of methylprednisolone (Solu-Medrol).
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d. IV 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.
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A patient with a neck fracture at the C5 level is admitted to the intensive care unit (ICU) following initial treatment in the emergency room. During initial assessment of the patient, the nurse recognizes the presence of spinal shock on finding
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a. hypotension, bradycardia, and warm extremities.
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b. involuntary, spastic movements of the arms and legs.
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c. the presence of hyperactive reflex activity below the level of the injury.
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d. flaccid paralysis and lack of sensation below the level of the injury.
ANS: D Clinical manifestations of spinal shock include decreased reflexes, loss of sensation, and flaccid paralysis below the area of injury. Hypotension, bradycardia, and warm extremities are evidence of neurogenic shock. Involuntary spastic movements and hyperactive reflexes are not seen in the patient at this stage of spinal cord injury
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When caring for a patient who had a C8 spinal cord injury 10 days ago and has a weak cough effort, bibasilar crackles, and decreased breath sounds, the initial intervention by the nurse should be to
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a. administer oxygen at 7 to 9 L/min with a face mask.
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b. place the hands on the epigastric area and push upward when the patient coughs.
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c. encourage the patient to use an incentive spirometer every 2 hours during the day.
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d. suction the patient�s oral and pharyngeal airway.
ANS: B The nurse has identified that the cough effort is poor, so 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, and oxygen will not help expel respiratory secretions. 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.
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As a result of a gunshot wound, a patient has an incomplete right spinal cord lesion at the level of T7, resulting in Brown-S�quard syndrome. Which nursing action should be included in the plan of care?
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a. Assessment of the patient for left leg pain
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b. Assessment of the patient for left arm weakness
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c. Positioning the patient�s right leg when turning the patient
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d. Teaching the patient to look at the left leg to verify its position
ANS: C The patient with Brown-S�quard 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 patient�s left leg. Left arm weakness will not be a problem for a patient with a T7 injury. The patient will retain position sense for the left leg.
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A patient with a T1 spinal cord injury is admitted to the intensive care unit (ICU). The nurse will teach the patient and family that
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a. use of the shoulders will be preserved.
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b. full function of the patient�s arms will be retained.
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c. total loss of respiratory function may occur temporarily.
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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. Total loss of respiratory function occurs with injuries above the C4 level and is permanent. Bradycardia is associated with injuries above the T6 level.
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