Question 1

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?

Accepted Answer

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.E) A) and B)
F) All of the above C, A, B, D

Question 2

When teaching patients who are at risk for Bell's palsy because of previous herpes simplex infection, which information should the nurse include?

Accepted Answer

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."E) A) and D)
F) C) and D)

Question 3

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

Accepted Answer

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.E) B) and C)
F) C) and D)

Question 4

During assessment of the patient with a recurrence of symptoms of trigeminal neuralgia, the nurse should

Accepted Answer

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.E) A) and B)
F) A) and C)

Question 5

When caring for a patient who has Guillain-Barré syndrome, which assessment data obtained by the nurse will require the most immediate action?

Accepted Answer

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.E) B) and D)
F) A) and B)

Question 6

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?

Accepted Answer

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 voidingE) A) and B)
F) A) and C)

Question 7

When caring for a patient who was admitted 24 hours previously with a C5 spinal cord injury, which nursing action has the highest priority?

Accepted Answer

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 legsE) None of the above
F) All of the above

Question 8

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

Accepted Answer

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.E) B) and C)
F) A) and C)

Question 9

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?

Accepted Answer

A)   Nasogastric tube feeding q4hr
B)   Artificial tear administration q2hr
C)   Assessment for bladder distension q2hr
D)   Passive range of motion to extremities q8hrE) A) and B)
F) B) and D)

Question 10

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

Accepted Answer

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.E) None of the above
F) B) and C)

Question 11

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

Accepted Answer

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.E) None of the above
F) A) and B)

Question 12

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?

Accepted Answer

A)   Maintain NPO status.
B)   Obtain lumbar puncture tray.
C)   Give magnesium citrate 8 oz now.
D)   Administer 1500-ml tapwater enema.E) B) and C)
F) None of the above C

Question 13

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

Accepted Answer

A)   monitoring the cardiac rhythm continuously.
B)   determining the level of consciousness q2hr.
C)   evaluating sensation and strength of the extremities.
D)   performing constant evaluation of respiratory function.E) A) and B)
F) B) and D)

Question 14

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

Accepted Answer

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.E) A) and B)
F) A) and C) A

Question 15

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

Accepted Answer

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) .E) A) and C)
F) B) and D)

Question 16

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.)

Accepted Answer

A)   Endotracheal suctioning
B)   Continuous cardiac monitoring
C)   Avoidance of cool room temperature
D)   Nasogastric tube feeding
E)   Retention catheter careF)  Administration of H2 receptor blockersG) D) and F)
H) B) and D)

Question 17

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

Accepted Answer

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.E) B) and D)
F) All of the above

Question 18

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

Accepted Answer

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.E) A) and C)
F) C) and D)

Question 19

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

Accepted Answer

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.E) All of the above
F) None of the above

Question 20

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

Accepted Answer

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.E) All of the above
F) A) and D)

Exam 61: Nursing Management: Peripheral Nerve and Spinal Cord Problems

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?

Correct Answer
verified
C, A, B, D

When teaching patients who are at risk for Bell's palsy because of previous herpes simplex infection, which information should the nurse include?

Correct Answer
verified

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

Correct Answer
verified

During assessment of the patient with a recurrence of symptoms of trigeminal neuralgia, the nurse should

Correct Answer
verified

When caring for a patient who has Guillain-Barré syndrome, which assessment data obtained by the nurse will require the most immediate action?

Correct Answer
verified

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?

Correct Answer
verified

When caring for a patient who was admitted 24 hours previously with a C5 spinal cord injury, which nursing action has the highest priority?

Correct Answer
verified

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

Correct Answer
verified

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?

Correct Answer
verified

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

Correct Answer
verified

Correct Answer
verified

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?

Correct Answer
verified
C

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

Correct Answer
verified

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

Correct Answer
verified
A

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

Correct Answer
verified

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.)

Correct Answer
verified

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

Correct Answer
verified

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

Correct Answer
verified

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

Correct Answer
verified

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

Correct Answer
verified

Exam 61: Nursing Management: Peripheral Nerve and Spinal Cord Problems

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?

Correct AnswerverifiedC, A, B, D

When teaching patients who are at risk for Bell's palsy because of previous herpes simplex infection, which information should the nurse include?

Correct AnswerverifiedShow Answer

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

Correct AnswerverifiedShow Answer

During assessment of the patient with a recurrence of symptoms of trigeminal neuralgia, the nurse should

Correct AnswerverifiedShow Answer

When caring for a patient who has Guillain-Barré syndrome, which assessment data obtained by the nurse will require the most immediate action?

Correct AnswerverifiedShow Answer

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?

Correct AnswerverifiedShow Answer

When caring for a patient who was admitted 24 hours previously with a C5 spinal cord injury, which nursing action has the highest priority?

Correct AnswerverifiedShow Answer

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

Correct AnswerverifiedShow Answer

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?

Correct AnswerverifiedShow Answer

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

Correct AnswerverifiedShow Answer

Correct AnswerverifiedShow Answer

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?

Correct AnswerverifiedC

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

Correct AnswerverifiedShow Answer

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

Correct AnswerverifiedA

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

Correct AnswerverifiedShow Answer

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.)

Correct AnswerverifiedShow Answer

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

Correct AnswerverifiedShow Answer

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

Correct AnswerverifiedShow Answer

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

Correct AnswerverifiedShow Answer

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

Correct AnswerverifiedShow Answer

Correct Answer
verified
C, A, B, D

Correct Answer
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Correct Answer
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Correct Answer
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Correct Answer
verified

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?

Correct Answer
verified

Correct Answer
verified

Correct Answer
verified

Correct Answer
verified

Correct Answer
verified

Correct Answer
verified

Correct Answer
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C

Correct Answer
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Correct Answer
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A

Correct Answer
verified

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.)

Correct Answer
verified

Correct Answer
verified

Correct Answer
verified

Correct Answer
verified

Correct Answer
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