Spinal Injury Week 6 Pt ll Quiz Questions

Question 1

A 20-yr-old male patient is admitted with a head injury after a collision while playing football. After noting that the patient has developed clear nasal drainage, which action should the nurse take?

a. Have the patient gently blow the nose.

b. Check the drainage for glucose content.

c. Teach the patient that rhinorrhea is expected after a head injury.

d. Obtain a specimen of the fluid to send for culture and sensitivity.

Answer 1

b. Check the drainage for glucose content.

Question 2

Admission vital signs for a patient who has a brain injury are blood pressure of 128/68 mm Hg, pulse of 110 beats/min, and of respirations 26 breaths/min. Which set of vital signs, if taken 1 hour later, will be of most concern to the nurse?

a. Blood pressure 154/68 mm Hg, pulse 56 beats/min, respirations 12 breaths/min
b. Blood pressure 134/72 mm Hg, pulse 90 beats/min, respirations 32 breaths/min
c. Blood pressure 148/78 mm Hg, pulse 112 beats/min, respirations 28 breaths/min
d. Blood pressure 110/70 mm Hg, pulse 120 beats/min, respirations 30 breaths/min

Answer 2

a. Blood pressure 154/68 mm Hg, pulse 56 beats/min, respirations 12 breaths/min

Question 3

Which action will the emergency department nurse anticipate for a patient diagnosed with a concussion who did not lose consciousness?

a. Coordinate the transfer of the patient to the operating room.

b. Provide discharge instructions about monitoring neurologic status.

c. Arrange to admit the patient to the neurologic unit for observation.

d. Transport the patient to radiology for magnetic resonance imaging (MRI).

Answer 3

b. Provide discharge instructions about monitoring neurologic status.

Rationale: A patient with a minor head trauma is usually discharged with instructions about neurologic monitoring and the need to return if neurologic status deteriorates. MRI, hospital admission, and surgery are not usually indicated in a patient with a concussion.

Question 4

The nurse is admitting a patient with a basal skull fracture (raccoon eyes). The nurse notes ecchymoses around both eyes and clear drainage from the patient’s nose. Which admission order should the nurse question?

a. Keep the head of bed elevated.
b. Insert nasogastric tube to low suction.
c. Turn patient side to side every 2 hours.
d. Apply cold packs intermittently to face.

Answer 4

b. Insert nasogastric tube to low suction.

Rhinorrhea may indicate a dural tear with cerebrospinal fluid leakage. Insertion of a nasogastric tube will increase the risk for infections such as meningitis. Turning the patient, elevating the head, and applying cold packs are appropriate orders.

Question 5

Which statement by a patient who is being discharged from the emergency department (ED) after a concussion indicates a need for intervention by the nurse?

a. “I will return if I feel dizzy or nauseated.”

b. “I am going to drive home and go right to bed.”

c. “I do not even remember being in an accident today.”

d. “I can take acetaminophen (Tylenol) for my headache.”

Answer 5

b. “I am going to drive home and go right to bed.”

Question 6

A college athlete is seen in the clinic 6 weeks after a concussion. Which assessment information will the nurse collect to determine whether the patient is developing postconcussion syndrome?

a. Short-term memory.

b. Muscle coordination.

c. Glasgow Coma Scale.

d. Pupil reaction to light.

Answer 6

a. Short-term memory.

Question 7

While admitting a 42-yr-old patient with a possible brain injury to the emergency department (ED), the nurse obtains the following information. Which finding is most important to report to the health care provider?

a. The patient reports a severe dull headache.

b. The patient takes warfarin (Coumadin) daily.

c. The patient’s blood pressure is 162/94 mm Hg.

d. The patient is unable to remember the accident.

Answer 7

b. The patient takes warfarin (Coumadin) daily.

The use of anticoagulants increases the risk for intracranial hemorrhage and should be immediately reported. The other information would not be unusual in a patient with a head injury who had just arrived in the ED.

Question 8

The nurse is caring for a patient with a subarachnoid hemorrhage who is intubated and placed on a mechanical ventilator with 10 cm HO of peak end-expiratory pressure (PEEP). When monitoring the patient, the nurse will need to notify the health care provider immediately if the patient develops:

a. oxygen saturation of 93%.
b. respirations of 20 breaths/minute.
c. green nasogastric tube drainage.
d. increased jugular venous distention.

Answer 8

d. increased jugular venous distention.

Question 9

A rehabilitation nurse is caring for a client who has had a spinal cord injury that resulted in paraplegia. After a week on the unit, the nurse notes that the client is withdrawn and increasingly resistant to rehabilitative efforts by the staff. Which of the following actions should the nurse take?

A. Inform the client that privileges are related to participation in therapy.
B. Limit visiting hours until the client begins to participate in therapy.
C. Allow the client to control the timing and frequency of the therapy.
D. Establish a plan of care with the client that sets attainable goals.

Answer 9

D. Establish a plan of care with the client that sets attainable goals.

Question 10

A nurse in the emergency department is monitoring a client who has a cervical spinal cord injury from a fall. The nurse should monitor the client for which of the following complications? (Select all that apply.)

A. Hypotension
B. Polyuria
C. Hyperthermia
D. Absence of bowel sounds
E. Weakened gag reflex

Answer 10

A. Hypotension
D. Absence of bowel sounds
E. Weakened gag reflex

Question 11

A nurse is caring for a client who has a T-4 spinal cord injury. Which of the following client findings should the nurse identify as an indication the client is at risk for experiencing autonomic dysreflexia?

a-The client states having a severe headache.
b-The client’s bladder becomes distended.
c-The client’s blood pressure becomes elevated.
d-The client states having nasal congestion.

Answer 11

b-The client’s bladder becomes distended.

Autonomic dysreflexia (sometimes called hyperreflexia) can occur in clients with a spinal cord injury at or above the T6 level. Autonomic dysreflexia happens when there is an irritation, pain, or stimulus to the nervous system below the level of injury. There are many kinds of stimulation that can precipitate autonomic dysreflexia. For example, catheter changes, a distended bladder or bowel, enemas, and sudden position changes. Manifestations include elevated blood pressure, severe headache, and flushed face.

Question 12

A nurse is caring for a client who has had a spinal cord injury at the level of the T2-T3 vertebrae. When planning care, the nurse should anticipate which of the following types of disability?

A. Paresthesia
B. Hemiplegia
C. Quadriplegia
D. Paraplegia

Answer 12

D. Paraplegia

Question 13

A nurse is developing a plan of care to prevent skin breakdown for a client with a spinal cord injury and paralysis. Which of the following nursing actions are appropriate? (Select all that apply.)

A. Massage over erythematous bony prominences.
B. Implement turning schedule every 4 hr.
C. Use pillows to keep heels off the bed surface.
D. Keep the client’s skin dry with powder.
E. Minimize skin exposure to moisture.

Answer 13

C. Use pillows to keep heels off the bed surface.
E. Minimize skin exposure to moisture.

Question 14

A nurse is caring for a client who has quadriplegia from a spinal cord injury and reports having a severe headache. The nurse obtains a blood pressure reading of 210/108 mm Hg and suspects the client is experiencing autonomic dysreflexia. Which of the following actions should the nurse take first?

A. Administer a nitrate antihypertensive.
B. Obtain the client’s heart rate.
C. Assess the client for bladder distention.
D. Place the client in a high-Fowler’s position.

Answer 14

D. Place the client in a high-Fowler’s position.

Question 15

A nurse is assessing a client who has a spinal cord injury. Which of the following actions should the nurse take to monitor C4 function?

A. Apply downward pressure while the client shrugs his shoulders upward.
B. Apply resistance while the client lifts his legs from the bed.
C. Ask the client to grasp an object and form a fist.
D. Apply resistance while the client flexes his arms.

Answer 15

A. Apply downward pressure while the client shrugs his shoulders upward.

This is using cranial nerve 11

Question 16

A nurse is assisting a client who has a spinal cord injury with bathing. Which of the following actions should the nurse take?

a. Offer the client bar soap.
b. Provide the client with a fixed shower head.
c. Give the client a long-handled sponge.
d. Fill the client’s bathtub with water at 48° C

Answer 16

c. Give the client a long-handled sponge.

Give the patient a long handle sponge to assist with bathing, bathwater no more than 115 degrees, wall mounted soap
dispenser, hand held shower head

Question 17

A nurse is caring for a client who is postoperative following a laminectomy with spinal fusion. Which of the following actions should the nurse take?

a. Monitor sensory perception of the lower extremities.
b. Assist the client into a knee-chest position to manage postoperative discomfort.
c. Maintain strict bed rest for the first 48 hours postoperative.
d. Position the client in a high-Fowler’s position if clear drainage is noted on the dressing.

Answer 17

a. Monitor sensory perception of the lower extremities.

Question 18

A nurse is caring for a client who has paraplegia following an automobile accident. The client is on an intermittent urinary catheterization program. Which of the following findings indicates the need for catheterization?

A. Urge incontinence
B. Dribbling of urine
C. Weight gain
D. Rectal distention

Answer 18

B. Dribbling of urine

Question 19

A nurse is assessing a client who has a traumatic head injury to determine motor function response. Which of the following client responses to painful stimulus is expected?

A.
Flexes the upper and extends the lower extremities in response to the painful stimulus

B.
Pushes the painful stimulus away

C.
Shows no reaction to the painful stimulus

D.
Extends her body toward the painful stimulus

Answer 19

B. Pushes the painful stimulus away

Question 20

A nurse is planning care for a client in a halo fixation device. What actions should the nurse include in the plan of care?
a) Monitor the client for an elevated temperature.
b) Provide range of motion to the client’s neck.
c) Remove the vest daily to inspect the client’s skin integrity.
d) Check that the halo jacket is snug against the client’s skin.

Answer 20

a) Monitor the client for an elevated temperature.

A halo fixation device is used to stabilize a cervical fracture on a client. The device is secured with four screws inserted directly into the client’s skull to promote cervical alignment. Complications include loose pins, local infection, and scarring. More serious complications include osteomyelitis, subdural abscess, and instability. The nurse should monitor and report manifestations of infection, such as fever and purulent drainage from pin sites

Question 21

A nurse is assessing a client who has Bell’s palsy. Which of the following findings should the nurse expect? SATA

A. Muscle distortion
B. Pain behind the ear
C. Hearing loss
D. Facial twitching
E. Impaired taste

Bell’s palsy SATA (3 answers) CN 7
-Impaired taste (difficulty with speech)
-Pain behind the ear *tinnitus nor hearing loss)
-Muscle distortion (Facial paralysis)

Answer 21

A. Muscle distortion
B. Pain behind the ear
E. Impaired taste

Question 22

A nurse in the ED is caring for a client who sustained a head injury. The nurse notes the client’s IV fluids are infusing at 125ml/hr. Which of the following is an appropriate nursing action by the nurse?
a- slow the rate to 20 mL/hr
b-continue the rate at 125 mL/hr
c-slow the rate to 50 mL/hr
d-increase the rate to 250 mL/hr

Answer 22

c-slow the rate to 50 mL/hr

Question 23

A person with a head injury and brief loss of consciousness and they have clear fluid coming out of the ear what does that
mean?

Answer 23

The fluid can be CSF and can indicate skull fracture

Question 24

A nurse is instructing a client’s family members about feeding safety for a client who has dysphagia following a stroke. Which of the following instructions should the nurse include?

A. Encourage brief exercise before meals to promote appetite.
B. Encourage the client to take small bites.
C. Place the client with the head reclined back to facilitate swallowing.
D. Place food in the affected side of the mouth.

Answer 24

B. Encourage the client to take small bites.

Question 25

A nurse is reinforcing discharge instructions with a client following a laminectomy. Which of the following instructions should the nurse include? a. "Sit in straight-back chairs." b. "Sleep on a soft mattress." c. "Walk around at least every 3 hours when sitting for long periods of time." d. "Bend at the waist when lifting objects."

Answer 25

a. "Sit in straight-back chairs."

Question 26

After the emergency department nurse has received a status report on the following patients who have been admitted with head injuries, which patient should the nurse assess first? a. A 20-yr-old patient whose cranial x-ray shows a linear skull fracture b. A 50-yr-old patient who has an initial Glasgow Coma Scale score of 13 c. A 30-yr-old patient who lost consciousness for a few seconds after a fall d. A 40-yr-old patient whose right pupil is 10 mm and unresponsive to light

Answer 26

d. A 40-yr-old patient whose right pupil is 10 mm and unresponsive to light

Question 27

What diuretic is a person with ICP and has a low GCS and cerebral hemorrhage going to get? Mannitol (osmotic diuretic)

Question 28

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

Answer 28

C. Positioning the patients left leg when turning the patient ** loss of motor function on the same side as cord damage ** ** loss of pain and temperature and light touch on the opposite side ** The patient with brown square 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

Question 29

A nurse is caring for a client who was involved in a motor vehicle accident. The client is alert and oriented and reports a loss of consciousness immediately after the accident. Which of the following additional manifestations should the nurse assess the client for? (Select All that Apply.) A. Pupillary dilation B. Persistent headache C. Presence of hand tremors D. Difficulty waking E. Foot drop

Answer 29

A. Pupillary dilation B. Persistent headache D. Difficulty waking

Question 30

A newly licensed nurse is learning about coup and contrecoup injuries. Which statement by the newly licensed nurse demonstrates a clear understanding of the topic? A. A contrecoup injury is not viewed as a “true” injury, while a coup injury can have more severe consequences. B. Contrecoup injuries are generally less severe and heal more quickly over time. C. The coup injury is the primary point of injury, with the contrecoup injury occurring on the brain’s opposite side. D. The coup injury happens secondary to the contrecoup injury but does not impact the brain’s blood supp

Answer 30

C. The coup injury is the primary point of injury, with the contrecoup injury occurring on the brain’s opposite side.

Question 31

A nurse is caring for a client who has a traumatic brain injury (TBI). Which of the following should the nurse understand is a possible consequence of a TBI? A. Increased blood supply and edema to the area of injury B. Damage to brain tissue from decreased pressure shock waves C. Disruption of cellular function and blood vessel damage D. Increased synaptic connections from pressure

Answer 31

C. Disruption of cellular function and blood vessel damage TBIs cause mechanical disruption to brain cells and vasculature, leading to secondary effects such as swelling, ischemia, and cellular dysfunction.

Question 32

A nurse is teaching the family of a client who is receiving treatment for a spinal cord injury with a halo fixation device. Which of the following statements should the nurse make? A. "Turn the screws on the device once each day." B. "The purpose of this device is to immobilize the cervical spine." C. "Apply talcum powder under the vest to limit friction." D. "The purpose of this device is to allow for neck movement during the healing process."

Answer 32

B. "The purpose of this device is to immobilize the cervical spine."

Question 33

The nurse is monitoring a postoperative craniotomy client with increased intracranial pressure (ICP). Which pharmacologic agent does the nurse expect to be requested to maintain the ICP within a specified range? A. Dexamethasone (Decadron) B. Hydrochlorothiazide (HydroDIURIL) C. Mannitol (Osmitrol) D. Phenytoin (Dilantin)

Answer 33

C. Mannitol (Osmitrol)

Question 34

A nurse is caring for a client who has a transection of the spinal cord at the level of cervical 7. Which of the following assessment findings should the nurse anticipate? A. The client has no sensation or movement below the level of the injury. B. The client has some movement but no sensation below the level of the injury. C. The client has some movement and also some sensation below the level of the injury. D. The client has some sensation but no movement below the level of the Injury.

Answer 34

A. The client has no sensation or movement below the level of the injury.

Question 35

A nurse is caring for a client who has a spinal cord injury at the first thoracic level. Which of the following should the nurse recognize can trigger autonomic dysreflexia?
(Select All that Apply.) A. Sexual intercourse B. Tight clothing C. Nausea D. Surgery below level of injury E. Urinary tract infections

Answer 35

A. Sexual intercourse B. Tight clothing D. Surgery below level of injury E. Urinary tract infections

Question 36

A patient with neurogenic shock is experiencing a heart rate of 30 bpm. What medication does the nurse anticipate will be ordered by the physician STAT? A. Adenosine B. Warfarin C. Atropine D. Norepinephrine

Answer 36

C. Atropine Atropine will increase the heart rate and block the effects of the parasympathetic system on the body. Remember bradycardia occurs in neurogenic shock because the sympathetic nervous system (which increases the heart rate) loses its ability to stimulate nerves. The sympathetic and parasympathetic systems are, in a way, balancing each other out when it comes to the heart rate. The sympathetic system increases it, while the parasympathetic decreases it. If the sympathetic system isn't working the way it should, it can NOT oppose the parasympathetic system....which will take over and lead to bradycardia.

Question 37

A 42-year-old male patient is admitted with a spinal cord injury. The patient is experiencing severe hypotension and bradycardia. The patient is diagnosed with neurogenic shock. Why is hypotension occurring in this patient with neurogenic shock? A. The patient has an increased systemic vascular resistance. This increases preload and decreases afterload, which will cause severe hypotension. B. The patient's autonomic nervous system has lost the ability to regulate the diameter of the blood vessels and vasodilation is occurring. C. The patient's parasympathetic nervous system is being unopposed by the sympathetic nervous system, which leads to severe hypotension. D. The increase in capillary permeability has depleted the fluid volume in the intravascular system, which has led to severe hypotension.

Answer 37

B. The patient's autonomic nervous system has lost the ability to regulate the diameter of the blood vessels and vasodilation is occurring. The sympathetic nervous system (which is a division of the autonomic nervous system) is unable to stimulate the nerves that regulate the diameter of the blood vessels (there's a loss of vasomotor tone). So, now the vessels are relaxed and this causes massive vasodilation. Systemic vascular resistance will decrease and hypotension will occur.

Question 38

A percutaneous radiofrequency rhizotomy procedure has been planned for a patient with trigeminal neuralgia. What information should the nurse give to this patient about the procedure? Select all that apply. A. Patient will be well-sedated during this procedure. B. A small craniotomy will be performed behind the ear. C. Patient may experience facial numbness after the surgery. D. Patient may have difficulty with eye movements after the procedure. E. Patient may have difficulty in masticating effectively for some time after the procedure.

Answer 38

C. Patient may experience facial numbness after the surgery. D. Patient may have difficulty with eye movements after the procedure. E. Patient may have difficulty in masticating effectively for some time after the procedure.

Question 39

A patient has undergone a percutaneous radiofrequency rhizotomy procedure for trigeminal neuralgia and has facial numbness and trigeminal motor weakness on the affected side. What instructions should the nurse give this patient? Select all that apply. A. Avoid eating hot food or beverages. B. Regularly shave using a razor blade. C. Avoid moving the jaw as much as possible. D. Protect the face from extreme temperatures. E. Check oral cavity after eating food for any residual food particles

Answer 39

A. Avoid eating hot food or beverages. D. Protect the face from extreme temperatures. E. Check oral cavity after eating food for any residual food particles

Question 40

T12 injury causes what disability

Answer 40

Walking, bladder, and bowel dysfunction **limited abdominal control**

Question 41

Cerebral aneurysm rupture interventions

Answer 41

Surgical procedure ▪ Microvascular clipping ▪ Endovascular therapy Drug therapy o Analgesics o Calcium channel blockers o Antiseizure medications

Question 42

A nurse is caring for a client who has an intracranial aneurysm and requires aneurysm precautions. Which of the following interventions should the nurse take? A. Place the client in protective isolation. B. Minimize environmental stimuli. C. Elevate the head of the client's bed 45°. D. Limit the client's ambulation to once a day.

Answer 42

B. Minimize environmental stimuli. A client who has a cerebral aneurysm is at risk for rupture and should avoid any stimulation that could cause anxiety, such as noise or bright lights.

Question 43

How do epidural hematomas present clinically?

Answer 43

**PowerPoint: Decreased LOC, headache, nausea and vomiting, or focal findings.** brief loss of consciousness followed by a lucid interval. Coma, headache, nausea/vomiting, focal neurological symptoms, rhinorrhea (CSF fluid).

Question 44

An older patient was found unconscious at home and was brought to the hospital. Upon arrival at the emergency department (ED), the patient regained consciousness and spoke with the nurses. During the initial assessment the patient complained of a headache immediately before losing consciousness again. These are all classic manifestations of which head trauma complication? A. Epidural hematoma B. Subdural hematoma C. Subacute hematoma D. Subarachnoid hematoma

Answer 44

A. Epidural hematoma Classic signs of an epidural hematoma include an initial period of unconsciousness at the scene, with a brief lucid interval followed by a decrease in level of consciousness (LOC). Other manifestations may be a headache, nausea and vomiting, or focal findings.