Chapter 61: Peripheral Nerve and Spinal Cord Problems NCLEX

Chapter 61: Peripheral Nerve and Spinal Cord Problems

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mo Which is most important to respond to in a patient presenting with a T3 spinal injury?

• Blood pressure of 88/60 mm Hg, pulse of 56

beats/minute

• Deep tendon reflexes of 1+, muscle strength of 1+
• Pain rated at 9
• Warm, dry skin
• Blood pressure of 88/60 mm Hg, pulse of 56 beats/minute

Neurogenic shock is a loss of vasomotor tone caused by injury, and it is characterized by hypotension and bradycardia. The loss of sympathetic nervous system innervations causes peripheral vasodilation, venous pooling, and a decreased cardiac output. The other options can be expected findings and are not as significant. Patients in neurogenic shock have pink and dry skin, instead of cold and clammy, but this sign is not as important as the vital signs.One month after a spinal cord injury, which finding is most important for you to monitor?

• Bladder scan indicates 100 mL.
• The left calf is 5 cm larger than the right calf.
• The heel has a reddened, nonblanchable area.
• Reflux bowel emptying.
• The left calf is 5 cm larger than the right calf.

Deep vein thrombosis is a common problem accompanying spinal cord injury during the first 3 months. Pulmonary embolism is one of the leading causes of death. Common signs and symptoms are absent. Assessment includes Doppler examination and measurement of leg girth. The other options are not as urgent to deal with as potential deep vein thrombosis.What is most important action for a patient who has a suspected cervical spinal injury?

• Apply a soft foam cervical collar.
• Perform a neurologic check.
• Place the patient on a firm surface.
• Assess function of cranial nerves IX and X.
• Place the patient on a firm surface.

A patient with a suspected cervical spine injury should be immobilized with a hard collar and placed on a firm surface. This takes priority over any further assessment.A soft foam collar does not provide immobilization.

The patient arrives in the emergency department from a motor vehicle accident, during which the car ran into a tree. The patient was not wearing a seat belt, and the windshield is shattered. What action is most important for you to do?

• Determine if the patient lost consciousness.
• Assess the Glasgow Coma Scale (GCS) score.
• Obtain a set of vital signs.
• Use a logroll technique when moving the patient.
• Use a logroll technique when moving the patient.

When the head hits the windshield with enough force to shatter it, you must assume neck or cervical spine trauma occurred and you need to maintain spinal precautions. This includes moving the patient in alignment as a unit or using a logroll technique during transfers. The other options are important and are done after spinal precautions are applied.Which patient should be assigned to the experienced registered nurse on a neurologic floor?

• Patient with trigeminal neuralgia reporting facial pain

rated at 10

• Patient with Bell's palsy with unilateral facial droop
• Patient after surgical removal of a spinal cord tumor

who is scheduled for discharge tomorrow

• Patient with traumatic injury to the cervical spinal cord

who was admitted today from the emergency department

• Patient with traumatic injury to the cervical spinal cord who was admitted today

from the emergency department The patient with the cervical spinal cord injury is potentially the most unstable and needs an experienced, professional nurse.You are caring for a patient admitted with a spinal cord injury after a motor vehicle accident. The patient exhibits a complete loss of motor, sensory, and reflex activity below the injury level. What is this condition?

• Central cord syndrome
• Spinal shock syndrome
• Anterior cord syndrome
• Brown-Séquard syndrome
• Spinal shock syndrome

About 50% of people with acute spinal cord injury experience a temporary loss of reflexes, sensation, and motor activity that is known as spinal shock. Central cord syndrome is manifested by motor and sensory loss greater in the upper extremities than the lower extremities. Anterior cord syndrome results in motor and sensory loss but not loss of reflexes. Brown-Séquard syndrome is characterized by ipsilateral loss of motor function and contralateral loss of sensory function.Which clinical manifestation do you interpret as representing neurogenic shock in a patient with acute spinal cord injury?

• Bradycardia
• Hypertension
• Neurogenic spasticity
• Bounding pedal pulses
• Bradycardia

Neurogenic shock results from loss of vasomotor tone caused by injury and is characterized by hypotension and bradycardia. Loss of sympathetic innervation causes peripheral vasodilation, venous pooling, and a decreased cardiac output.You are caring for a patient admitted 1 week earlier with an acute spinal cord injury. Which assessment finding alerts you to the presence of autonomic dysreflexia?

• Tachycardia
• Hypotension
• Hot, dry skin
• Throbbing headache
• Throbbing headache

Autonomic dysreflexia is related to reflex stimulation of the sympathetic nervous system, which is reflected by hypertension, bradycardia, throbbing headache, and diaphoresis.When planning care for a patient with a C5 spinal cord injury, which nursing diagnosis is the highest priority?

• Impaired tissue integrity due to paralysis
• Impaired urinary elimination due to quadriplegia
• Ineffective coping due to the extent of trauma
• Ineffective airway clearance due to high cervical spinal

cord injury

• Ineffective airway clearance due to high cervical spinal cord injury

Maintaining a patent airway is the most important goal for a patient with a high cervical fracture. Although all of these options are appropriate nursing diagnoses for a patient with a spinal cord injury, respiratory needs are always the highest priority. Remember the ABCs.

Which signs and symptoms in a patient with a T4 spinal cord injury should alert you to the possibility of autonomic dysreflexia?

• Headache and rising blood pressure
• Irregular respirations and shortness of breath
• Decreased level of consciousness or hallucinations
• Abdominal distention and absence of bowel sounds
• Headache and rising blood pressure

Among the manifestations of autonomic dysreflexia are hypertension (up to 300 mm Hg systolic) and throbbing headache. Respiratory manifestations, decreased level of consciousness, and gastrointestinal manifestations are not characteristic.Which intervention should you perform in the acute care of a patient with autonomic dysreflexia?

• Urinary catheterization
• Administration of benzodiazepines
• Suctioning of the patient's upper airway
• Placement of the patient in the Trendelenburg position
• Urinary catheterization

Because the most common cause of autonomic dysreflexia is bladder irritation, immediate catheterization to relieve bladder distention may be necessary. The patient should be positioned upright. Benzodiazepines are contraindicated, and suctioning is likely unnecessary.A patient is admitted to the intensive care unit (ICU) with a C7 spinal cord injury and diagnosed with Brown- Séquard syndrome. What would you most likely find on physical examination?

• Upper extremity weakness only
• Complete motor and sensory loss below C7
• Loss of position sense and vibration in both lower

extremities

• Ipsilateral motor loss and contralateral sensory loss

below C7

• Ipsilateral motor loss and contralateral sensory loss below C7

Brown-Séquard syndrome is a result of damage to one half of the spinal cord. This syndrome is characterized by a loss of motor function and position and vibratory sense, as well as vasomotor paralysis on the same side (ipsilateral) as the lesion.The opposite (contralateral) side has loss of pain and temperature sensation below the level of the lesion.A patient is admitted to the hospital with a C4 spinal cord injury after a motorcycle collision. The patient's blood pressure is 83/49 mm Hg and pulse is 39 beats/minute.He remains orally intubated. What is the cause of this pathophysiologic response?

• Increased vasomotor tone after the injury
• A temporary loss of sensation and flaccid paralysis

below the level of injury

• Loss of parasympathetic nervous system innervation

resulting in vasoconstriction

• Loss of sympathetic nervous system innervation

resulting in peripheral vasodilation

• Loss of sympathetic nervous system innervation resulting in peripheral

vasodilation eurogenic shock results from loss of vasomotor tone caused by injury, and it is characterized by hypotension and bradycardia. Loss of sympathetic nervous system innervation causes peripheral vasodilation, venous pooling, and a decreased cardiac output. These effects usually are associated with a cervical or high thoracic injury (T6 or higher).What are the goals of rehabilitation for the patient with an injury at the C6 level (select all that apply)?

• Stand erect with leg brace
• Feed self with hand devices
• Drive an electric wheelchair
• Assist with transfer activities
• Drive adapted van from wheel chair
• Feed self with hand devices
• Drive an electric wheelchair
• Assist with transfer activities
• Drive adapted van from wheel chair

Rehabilitation goals for a patient with a spinal cord injury at the C6 level include ability to assist with transfer and perform some self-care; feed self with hand devices; push wheelchair on smooth, flat surface; drive adapted van from wheelchair; independent computer use with adaptive equipment; and needing attendant care only for 6 hours per day.

A patient with a C7 spinal cord injury undergoing rehabilitation tells you he must have the flu because he has a bad headache and nausea. What is your initial action?

• Call the physician.
• Check the patient's temperature.
• Take the patient's blood pressure.
• Elevate the head of the bed to 90 degrees.
• Take the patient's blood pressure.

Autonomic dysreflexia is a massive, uncompensated cardiovascular reaction mediated by the sympathetic nervous system. Manifestations include hypertension (up to 300 mm Hg systolic), throbbing headache, marked diaphoresis above the level of the lesion, bradycardia (30 to 40 beats/minute), piloerection, flushing of the skin above the level of the lesion, blurred vision or spots in the visual fields, nasal congestion, anxiety, and nausea. It is important to measure blood pressure when a patient with a spinal cord injury complains of a headache.For a 65-year-old female patient who has lived with a T1 spinal cord injury for 20 years, which health teaching information should you emphasize?

• A mammogram is needed every year.
• Bladder function tends to improve with age.
• Heart disease is not common in persons with spinal

cord injury.

• As a person ages, the need to change body position is

less important.

• A mammogram is needed every year.

Health promotion and screening are important for the older patient with a spinal cord injury. Older adult women with spinal cord injuries should perform monthly breast examinations and yearly mammograms The nurse performs discharge teaching for a 34-year-old male patient with a T2 spinal cord injury resulting from a construction accident. Which statement, if made by the patient to the nurse, indicates that teaching about recognition and management of autonomic dysreflexia is successful?

• "I will perform self-catheterization at least six times per

day."

• "A reflex erection may cause an unsafe drop in blood

pressure."

• "If I develop a severe headache, I will lie down for 15 to

20 minutes."

• "I can avoid this problem by taking medications to

prevent leg spasms." a Autonomic dysreflexia is usually caused by a distended bladder. Performing self- catheterization five or six times a day prevents bladder distention. Signs and symptoms of autonomic dysreflexia include a severe headache. Patients should raise the head of the bed to 45 to 90 degrees. This action helps to relieve hypertension (systolic pressure up to 300 mm Hg) that occurs with autonomic dysreflexia.A 22-year-old female with paraplegia after a spinal cord injury tells the home care nurse that bowel incontinence occurs two or three times each day. Which action by the nurse is most appropriate?

• Take magnesium citrate (Citroma) every morning with

breakfast.

• Teach the patient to gradually increase intake of high-

fiber foods.

• Assess bowel movements for frequency, consistency,

and volume.

• Instruct the patient to avoid all caffeinated and

carbonated beverages c The nurse should establish baseline bowel function and explore the patient's current knowledge of an appropriate bowel management program after spinal cord injury. To prevent constipation, caffeine intake should be limited, but not eliminated. Oral saline laxatives such as magnesium citrate are not indicated for long-term management of bowel elimination. Instruction on high-fiber foods is indicated if the patient has a knowledge deficit.