Spinal Cord Problems NCLEX

Spinal Cord Problems NCLEX ScienceMedicineNursing vegalisa Save Spinal Cord Injury NCLEX 26 terms ET0003Preview Spinal cord Injuries, Herniated Dis...10 terms amanda_scott512 Preview NCLEX Questions Parkinson Disease...20 terms SMathews926Preview Amyot 12 terms Cou A nurse plans care for a client with lower back pain from a work-related injury. Which intervention should the nurse include in this client's plan of care?

• Encourage the client to stretch the back by reaching toward the toes.
• Massage the affected area with ice twice a day.
• Apply a heating pad for 20 minutes at least four times daily.
• Advise the client to avoid warm baths or showers.

C ~ Heat increases blood flow to the affected area and promotes healing of injured nerves. Stretching and ice will not promote healing, and there is no need to avoid warm baths or showers.A nurse assesses a client who is recovering from a diskectomy 6 hours ago. Which assessment finding should the nurse address first?

• Sleepy but arouses to voice
• Dry and cracked oral mucosa
• Pain present in lower back
• Bladder palpated above pubis

D ~ A distended bladder may indicate damage to the sacral spinal nerves. The other findings require the nurse to provide care but are not the priority or a complication of the procedure.A nurse teaches a client who is recovering from a spinal fusion. Which statement should the nurse include in this client's postoperative instructions?

• Only lift items that are 10 pounds or less.
• Wear your brace whenever you are out of bed.
• You must remain in bed for 3 weeks after surgery.
• You are prescribed medications to prevent rejection.

B ~ Clients who undergo spinal fusion are fitted with a brace that they must wear throughout the healing process (usually 3 to 6 months) whenever they are out of bed. The client should not lift anything. The client does not need to remain in bed. Medications for rejection prevention are not necessary for this procedure.

A nurse assesses a client who is recovering from anterior cervical diskectomy and fusion. Which complication should alert the nurse to urgently communicate with the health care provider?

• Auscultated stridor
• Weak pedal pulses
• Difficulty swallowing
• Inability to shrug shoulders

A ~ Postoperative swelling can narrow the trachea, cause a partial airway obstruction, and manifest as stridor. The client may also have trouble swallowing, but maintaining an airway takes priority. Weak pedal pulses and an inability to shrug the shoulders are not complications of this surgery.A nurse assesses a client with a spinal cord injury at level T5. The clients blood pressure is 184/95 mm Hg, and the client presents with a flushed face and blurred vision. Which action should the nurse take first?

• Initiate oxygen via a nasal cannula.
• Place the client in a supine position.
• Palpate the bladder for distention.
• Administer a prescribed beta blocker.

C ~ 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. The other actions would not be appropriate.An emergency room nurse initiates care for a client with a cervical spinal cord injury who arrives via emergency medical services. Which action should the nurse take first?

• Assess level of consciousness.
• Obtain vital signs.
• Administer oxygen therapy.
• Evaluate respiratory status.

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. The other assessments should be performed after airway and breathing are assessed.An emergency department nurse cares for a client who experienced a spinal cord injury 1 hour ago. Which prescribed medication should the nurse prepare to administer?

• Intrathecal baclofen (Lioresal)
• Methylprednisolone (Medrol)
• Atropine sulfate
• Epinephrine (Adrenalin)

B ~ Methylprednisolone (Medrol) should be given within 8 hours of the injury. Clients who receive this therapy usually show improvement in motor and sensory function. The other medications are inappropriate for this client.

A nurse teaches a client with a lower motor neuron lesion who wants to achieve bladder control. Which statement should the nurse include in this clients teaching?

• Stroke the inner aspect of your thigh to initiate voiding.
• Use a clean technique for intermittent catheterization.
• Implement digital anal stimulation when your bladder is full.
• Tighten your abdominal muscles to stimulate urine flow.

D ~ In clients with lower motor neuron problems such as spinal cord injury, performing a Valsalva maneuver or tightening the abdominal muscles are interventions that can initiate voiding. Stroking the inner aspect of the thigh may initiate voiding in a client who has an upper motor neuron problem. Intermittent catheterization and digital anal stimulation do not initiate voiding or bladder control.A nurse is caring for a client with paraplegia who is scheduled to participate in a rehabilitation program. The client states, "I do not understand the need for rehabilitation; the paralysis will not go away and it will not get better." How should the nurse respond?

• If you don't want to participate in the rehabilitation program, Ill let the provider know.
• Rehabilitation programs have helped many clients with your injury. You should give it a chance.
• The rehabilitation program will teach you how to maintain the functional ability you have and prevent further disability.
• When new discoveries are made regarding paraplegia, people in rehabilitation programs will benefit first.

C ~ Participation in rehabilitation programs has many purposes, including prevention of disability, maintenance of functional ability, and restoration of function. The other responses do not meet this client's needs.After teaching a client with a spinal cord injury, the nurse assesses the client's understanding. Which client statement indicates a correct understanding of how to prevent respiratory problems at home?

• I'll use my incentive spirometer every 2 hours while I'm awake.
• I'll drink thinned fluids to prevent choking.
• I'll take cough medicine to prevent excessive coughing.
• I'll position myself on my right side so I don't aspirate.

A ~ Often, the person with a spinal cord injury will have weak intercostal muscles and is at higher risk for developing atelectasis and stasis pneumonia. Using an incentive spirometer every 2 hours helps the client expand the lungs more fully and prevents atelectasis. Clients should drink fluids that they can tolerate; usually thick fluids are easier to tolerate. The client should be encouraged to cough and clear secretions.Clients should be placed in high-Fowlers position to prevent aspiration.A nurse assesses a client with early-onset multiple sclerosis (MS). Which clinical manifestation should the nurse expect to find?

• Hyperresponsive reflexes
• Excessive somnolence
• Nystagmus
• Heat intolerance

C ~ Early signs and symptoms of MS include changes in motor skills, vision, and sensation. Hyperresponsive reflexes, excessive somnolence, and heat intolerance are later manifestations of MS.A nurse cares for a client who presents with an acute exacerbation of multiple sclerosis (MS). Which prescribed medication should the nurse prepare to administer?

• Baclofen (Lioresal)
• Interferon beta-1b (Betaseron)
• Dantrolene sodium (Dantrium)
• Methylprednisolone (Medrol)

D ~ Methylprednisolone is the drug of choice for acute exacerbations of the disease. The other drugs are not used to treat acute exacerbations of MS. Interferon beta-1b is used to treat and control MS, decrease specific symptoms, and slow the progression of the disease. Baclofen and dantrolene sodium are prescribed to lessen muscle spasticity associated with MS.

A nurse assesses a client with multiple sclerosis after administering prescribed fingolimod (Gilenya). For which adverse effect should the nurse monitor?

• Peripheral edema
• Black tarry stools
• Bradycardia
• Nausea and vomiting

C ~ Fingolimod (Gilenya) is an antineoplastic agent that can cause bradycardia, especially within the first 6 hours after administration. Peripheral edema, black and tarry stools, and nausea and vomiting are not adverse effects of fingolimod.A nurse is teaching a client with multiple sclerosis who is prescribed cyclophosphamide (Cytoxan) and methylprednisolone (Medrol). Which statement should the nurse include in this clients discharge teaching?

• Take warm baths to promote muscle relaxation.
• Avoid crowds and people with colds.
• Relying on a walker will weaken your gait.
• Take prescribed medications when symptoms occur.

B ~ The client should be taught to avoid people with any type of upper respiratory illness because these medications are immunosuppressive.Warm baths will exacerbate the clients symptoms. Assistive devices may be required for safe ambulation. Medication should be taken at all times and should not be stopped.A nurse assesses a client with a neurologic disorder. Which assessment finding should the nurse identify as a late manifestation of amyotrophic lateral sclerosis (ALS)?

• Dysarthria
• Dysphagia
• Muscle weakness
• Impairment of respiratory muscles

D ~ In ALS, progressive muscle atrophy occurs until a flaccid quadriplegia develops. Eventually, the respiratory muscles are involved, which leads to respiratory compromise. Dysarthria, dysphagia, and muscle weakness are early clinical manifestations of ALS.A nurse cares for several clients on a neurologic unit. Which prescription for a client should direct the nurse to ensure that an informed consent has been obtained before the test or procedure?

• Sensation measurement via the pinprick method
• Computed tomography of the cranial vault
• Lumbar puncture for cerebrospinal fluid sampling
• Venipuncture for autoantibody analysis

C ~ A lumbar puncture is an invasive procedure with many potentially serious complications. The other assessments or tests are considered noninvasive and do not require an informed consent.A nurse prepares a client for prescribed magnetic resonance imaging (MRI). Which action should the nurse implement prior to the test?

• Implement nothing by mouth (NPO) status for 8 hours.
• Withhold all daily medications until after the examination.
• Administer morphine sulfate to prevent claustrophobia during the test.
• Place the client in a gown that has cloth ties instead of metal snaps.

D ~ Metal objects are a hazard because of the magnetic field used in the MRI procedure. Morphine sulfate is not administered to prevent claustrophobia; lorazepam (Ativan) or diazepam (Valium) may be used instead. The client does not need to be NPO, and daily medications do not need to be withheld prior to MRI.