Ch. 61

  1. When assessing a patient with newly diagnosed trigeminal neuralgia, the nurse will ask the patient about

    a. triggers that lead to facial pain.

    b. visual problems caused by ptosis.

    c. poor appetite caused by a loss of taste.

    d. decreased sensation on the affected side.
    ANS: D 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 numbness are not characteristics of trigeminal neuralgia, although ptosis and numbness may occur after therapy, and poor appetite may be associated with pain stimulated by eating.
  2. During assessment of the patient with a recurrence of symptoms of trigeminal neuralgia, the nurse should

    a. examine the mouth and teeth thoroughly.

    b. have the patient clench and relax the jaw and eyes.

    c. identify trigger zones by lightly touching the affected side.

    d. gently palpate the face to compare skin temperature bilaterally.
    ANS: A 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.
  3. A patient with trigeminal neuralgia has a glycerol rhizotomy. During a follow-up visit after the rhizotomy, the nurse will evaluate that the patient has had a successful outcome for the surgery if the patient

    a. uses an eye shield at night to protect the cornea from injury.

    b. develops and implements a daily routine of facial exercises.

    c. is careful to chew foods on the unaffected side of the mouth.

    d. talks about enjoying social activities with family and friends.
    ANS: D Because withdrawal from social activities is a common manifestation of trigeminal neuralgia, enjoyment of social activities indicates successful reduction of symptoms. 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.
  4. When the nurse is planning care for a hospitalized patient who is experiencing an acute episode of trigeminal neuralgia, an appropriate action to include is

    a. teach facial and jaw relaxation techniques.

    b. assess intake and output and dietary intake.

    c. apply ice packs for no more than 20 minutes.

    d. spend time at the bedside talking with the patient.
    ANS: B 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.
  5. When teaching patients who are at risk for Bell’s palsy because of previous herpes simplex infection, which information should the nurse include?

    a. “You should call the doctor if pain or herpes lesions occur near the ear.”

    b. “Treatment of herpes with antiviral agents will prevent development of Bell’s palsy.”

    c. “Medications to treat Bell’s palsy work only if started before paralysis onset.”

    d. “You may be able to prevent Bell’s palsy by doing facial exercises regularly.”
    ANS: A 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.
  6. A patient with Bell’s palsy refuses to eat while others are present because of embarrassment about drooling. The best response by the nurse to the patient’s behavior is to

    a. respect the patient’s desire and arrange for privacy at mealtimes.

    b. offer the patient liquid nutritional supplements at frequent intervals.

    c. discuss the patient’s concerns with visitors who arrive at mealtimes.

    d. teach the patient to chew food on the unaffected side of the mouth.
    ANS: A The patient’s desire for privacy should be respected to encourage adequate nutrition and reduce patient embarrassment. Liquid supplements 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.
  7. A patient with Guillain-Barré syndrome asks the nurse what has caused the disease. In responding to the patient, the nurse explains that Guillain-Barré syndrome

    a. results from an acute infection and inflammation of the peripheral nerves.

    b. is due to an immune reaction that attacks the covering of the peripheral nerves.

    c. is caused by destruction of the peripheral nerves after exposure to a viral infection.

    d. results from degeneration of the peripheral nerve caused by viral attacks.
    ANS: B Guillain-Barré 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.
  8. A 24-year-old patient is hospitalized with the onset of Guillain-Barré syndrome. During this phase of the patient’s illness, the most essential assessment for the nurse to carry out is

    a. monitoring the cardiac rhythm continuously.

    b. termining the level of consciousness q2hr.

    c. evaluating sensation and strength of the extremities.

    d. performing constant evaluation of respiratory function.
    ANS: D The most serious complication of Guillain-Barré 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.
  9. When caring for a patient who has Guillain-Barré syndrome, which assessment data obtained by the nurse will require the most immediate action?

    a. The patient complains of severe tingling pain in the feet.

    b. The patient has continuous drooling of saliva.

    c. The patient’s blood pressure (BP) is 106/50 mm Hg.

    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-Barré syndrome
  10. A patient who has numbness and weakness of both feet is hospitalized with Guillain-Barré syndrome. The nurse will anticipate that collaborative interventions at this time will include

    a. intubation and mechanical ventilation.

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

    c. administration of methylprednisolone (Solu-Medrol).

    d. IV infusion of immunoglobulin (Sandoglobulin).
    ANS: D 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.
  11. A patient admitted to the emergency department is diagnosed with botulism, and an order for botulinum antitoxin is received. Before administering the antitoxin, it is most important for the nurse to

    a. obtain baseline vital signs.

    b. administer an intradermal test dose.
    c. ask the patient about a history of allergies.

    d. document the presence of neurologic symptoms.
    ANS: B To prevent allergic reactions, an intradermal test dose of the antitoxin should be administered. Although baseline vital signs, allergy history, and symptom assessment and documentation are appropriate, these assessments will not impact on the decision to administer the antitoxin
  12. A patient arrives at an urgent care center with a deep puncture wound after stepping on a nail that was embedded in some old lumber in a field. The patient reports having had a tetanus booster 7 years ago. The nurse will anticipate

    a. IV infusion of tetanus immune globulin (TIG).

    b. initiation of the tetanus-diphtheria immunization series.

    c. intradermal injection of an immune globulin test dose.

    d. administration of the tetanus-diphtheria (Td) toxoid booster.
    ANS: D 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. A test dose is not needed for immune globulin, and TIG is not indicated for the patient.
  13. 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

    a. hypotension, bradycardia, and warm extremities.

    b. involuntary, spastic movements of the arms and legs.

    c. the presence of hyperactive reflex activity below the level of the injury.

    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
  14. 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

    a. administer oxygen at 7 to 9 L/min with a face mask.

    b. place the hands on the epigastric area and push upward when the patient coughs.

    c. encourage the patient to use an incentive spirometer every 2 hours during the day.

    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.
  15. As a result of a gunshot wound, a patient has an incomplete right 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 left leg pain

    b. Assessment of the patient for left arm weakness

    c. Positioning the patient’s right leg when turning the patient

    d. Teaching the patient to look at the left 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 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.
  16. 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

    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. Total loss of respiratory function occurs with injuries above the C4 level and is permanent. Bradycardia is associated with injuries above the T6 level.
  17. The health care provider orders administration of IV methylprednisolone (Solu-Medrol) for the first 24 hours to a patient who experienced a spinal cord injury at the T10 level 3 hours ago. When evaluating the effectiveness of the medication the nurse will assess

    a. blood pressure and heart rate.

    b. respiratory effort and O2 saturation.
    c. motor and sensory function of the legs.

    d. bowel sounds and abdominal distension.
    ANS: C The purpose of methylprednisolone administration is to help preserve neurologic function; therefore, the nurse will assess this patient for lower-extremity function. Sympathetic nervous system dysfunction occurs with injuries at or above T6, so monitoring of BP and heart rate will not be useful in determining the effectiveness of the medication. Respiratory and GI function will not be impaired by a T10 injury, so assessments of these systems will not provide information about whether the medication is effective.
  18. A patient with a paraplegia resulting from a T10 spinal cord injury has a neurogenic reflex bladder. When the nurse develops a plan of care for this problem, which nursing action will be most appropriate?

    a. Teaching the patient how to self-catheterize

    b. Assisting the patient to the toilet q2-3hr

    c. Use of the Credé method to empty the bladder

    d. Catheterization for residual urine after voiding
    ANS: A 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.
  19. A patient with a history of a T2 spinal cord 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. Notify the patient’s health care provider.

    b. Check the blood pressure (BP).

    c. Give the ordered antiemetic.

    d. Assess for a fecal impaction.
    ANS: B 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 causing the symptoms, including hypertension. 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.
  20. The nurse discusses long-range goals with a patient with a C6 spinal cord injury. An appropriate patient outcome is

    a. transfers independently to a wheelchair.

    b. drives a car with powered hand controls.

    c. turns and repositions self independently when in bed.

    d. pushes 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.
  21. A patient who sustained a T1 spinal cord injury a week ago refuses to discuss the injury and becomes verbally abusive to the nurses and other staff. The patient demands to be transferred to another hospital, where “they know what they are doing.” The best response by the nurse to the patient’s behavior is to

    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 that the anger will pass and rehabilitation will then progress.

    d. ignore the patient’s anger and continue to perform needed assessments and care.
    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. Refusal to acknowledge the patient’s anger by telling the patient that the anger is just a phase is inappropriate. Continuing to perform needed assessments and care is appropriate, but the nurse should seek the patient’s input into what care is needed
  22. A 26-year-old patient with a C8 spinal cord injury tells the nurse, “My wife and I have always had a very active sex life, and I am worried that she may leave me if I cannot function sexually.” The most appropriate response by the nurse to the patient’s comment is to

    a. advise the patient to talk to his wife to determine how she feels about his sexual function.

    b. tell the patient that sildenafil (Viagra) helps to decrease erectile dysfunction in patients with spinal cord injury.

    c. inform the patient that most patients with upper motor neuron injuries have reflex erections.

    d. suggest that the patient and his wife work with a nurse specially trained in sexual counseling.
    ANS: D Maintenance of sexuality is an important aspect of rehabilitation after spinal cord injury and should be handled by someone with expertise in sexual counseling. Although the patient should discuss these issues with his wife, open communication about this issue may be difficult without the assistance of a counselor. Sildenafil does assist with erectile dysfunction after spinal cord injury, but the patient’s sexuality is not determined solely by the ability to have an erection. Reflex erections are common after upper motor neuron injury, but these erections are uncontrolled and cannot be maintained during coitus.
  23. A 25-year-old patient has returned home following extensive rehabilitation for a C8 spinal cord injury. The home care nurse visits and notices that the patient’s spouse and parents are performing many of the activities of daily living (ADLs) that the patient had been managing during rehabilitation. The most appropriate action by the nurse at this time is to

    a. tell the family members that the patient can perform ADLs independently.

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

    c. recognize that it is important for the patient’s family to be involved in the patient’s care and support their activities.

    d. develop a plan to increase the patient’s independence in consultation with the with the patient, spouse, and parents.
    ANS: D 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 family that the patient can perform ADLs independently is not the best choice. Reminding the patient about the importance of independence may not change the behaviors of the family members. Supporting the activities of the spouse and parents will lead to ongoing dependency by the patient.
  24. The nurse is caring for a patient who is being evaluated for a possible metastatic spinal cord tumor. Which of these data obtained when assessing the patient requires most immediate action by the nurse?

    a. The patient has new onset weakness of both legs.

    b. The patient complains of chronic level 6 pain on a 10-point scale.

    c. The patient starts to cry and says, “I feel hopeless.”

    d. The patient expresses anxiety about having surgery.
    ANS: A The new onset of symptoms indicates cord compression, an emergency that requires rapid treatment to avoid permanent loss of function. The other patient assessments also indicate a need for nursing action but do not require intervention as rapidly as the new onset weakness
  25. Which of these nursing actions for a patient with Guillain-Barré syndrome is most appropriate for the nurse to delegate to an experienced nursing assistant?

    a. Nasogastric tube feeding q4hr

    b. Artificial tear administration q2hr

    c. Assessment for bladder distension q2hr

    d. Passive range of motion to extremities q8hr
    ANS: D Assisting a patient with movement is included in nursing assistant education and scope of practice. Administration of tube feedings, administration of ordered medications, and assessment are skills requiring more education and scope of practice, and the RN should perform these skills.
  26. A patient with possible botulism poisoning is admitted for observation and administration of botulinum antitoxin. Which of the following health care provider orders should the nurse question?

    a. Maintain NPO status.

    b. Obtain lumbar puncture tray.

    c. Give magnesium citrate 8 oz now.

    d. Administer 1500-ml tapwater enema.
    ANS: C Magnesium is contraindicated because it may worsen the neuromuscular blockade. The other orders are appropriate for the patient.
  27. 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. Continuous cardiac monitoring for bradycardia

    b. Administration of methylprednisolone (Solu-Medrol) infusion

    c. Assessment of respiratory rate and depth

    d. Application of pneumatic compression devices to both legs
    ANS: C 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 are also appropriate but are not as important as assessment of respiratory effort.
  28. 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. Endotracheal suctioning

    b. Continuous cardiac monitoring

    c. Avoidance of cool room temperature

    d. Nasogastric tube feeding

    e. Retention catheter care

    f. Administration of H2 receptor blockers
    ANS: B, C, E, F 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 distension, a 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.
  29. In which order will the nurse perform the following actions when caring for a patient with possible cervical spinal cord trauma who is admitted to the emergency department?
    a. Administer O2 using a non-rebreathing mask.
    b. Monitor cardiac rhythm and blood pressure.
    c. Immobilize the patient’s head, neck, and spine.
    d. Transfer the patient to radiology for spinal CT.
    • ANS: C, A, B, 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, continuous monitoring of heart rhythm and BP is indicated. CT scan to determine the extent and level of injury is needed once initial assessment and stabilization is accomplished.
Card Set
Ch. 61