Questions and Answers
A patient admitted with dermal ulcers who has a history of a T3 spinal cord injury tells the nurse, "I have a pounding headache and I feel sick to my stomach." Which action should the nurse take first?
A patient is being evaluated for a possible spinal cord tumor. Which finding by the nurse requires the most immediate action?
Which of these nursing actions for a patient with Guillain-Barré syndrome is appropriate for the nurse to delegate to experienced unlicensed assistive personnel (UAP)?
Which action will the nurse take when caring for a patient who develops tetanus from injectable substance use?
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Which action will the nurse include in the plan of care for a patient who has a cauda equina spinal cord injury?
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After change-of-shift report on the neurology unit, which patient will the nurse assess first?
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Which finding in a patient with a spinal cord tumor requires an immediate report to the health care provider?
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A patient with a T4 spinal cord injury asks the nurse if he will be able to be sexually active. Which initial response by the nurse is best?
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When caring for a patient who experienced a T2 spinal cord transection 24 hours ago, which collaborative and nursing actions will the nurse include in the plan of care? (Select all that apply)
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A patient with neurogenic shock after a spinal cord injury is to receive lactated Ringer's solution 400 mL over 20 minutes. When setting the IV pump to deliver the IV fluid, the nurse will set the rate at how many milliliters per hour?
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In which order will the nurse perform the following actions when caring for a patient with possible C5 spinal cord trauma? (Put a comma and a space between each answer choice)
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What will the nurse ask the patient with newly diagnosed trigeminal neuralgia?
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Which patient assessment will help the nurse identify potential complications of trigeminal neuralgia?
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When evaluating outcomes of a glycerol rhizotomy for a patient with trigeminal neuralgia, what should the nurse ask?
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Which action will the nurse include in the plan of care for a patient who is experiencing pain from trigeminal neuralgia?
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What should the nurse teach to a patient at risk for Bell's palsy?
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What is the best response by the nurse for a patient with Bell's palsy who is embarrassed about drooling?
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To prevent autonomic hyperreflexia, which nursing action will the home health nurse include in the plan of care for a patient with paraplegia at the T4 level?
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Which assessment data for a patient with Guillain-Barré syndrome requires the nurse's most immediate action?
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What should the nurse anticipate teaching a patient hospitalized with a new diagnosis of Guillain-Barré syndrome who has numbness and weakness of both feet?
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What should the nurse expect for a construction worker with a deep puncture wound from a rusty nail?
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Which assessment findings indicate neurogenic shock for a patient with a neck fracture at the C6 level?
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What nursing action should be included in the care plan for a patient with Brown-Séquard syndrome?
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What should the nurse explain to the patient with a T2 spinal cord transection injury?
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What action will the nurse include in the plan of care for a patient with a neurogenic reflexic bladder?
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What is an appropriate goal for a patient with a C6 spinal cord injury?
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What should the nurse do when a patient suffering from grief expresses anger about their transfer?
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What should the home care nurse do when observing a spouse engaged in many activities that the patient had been managing independently?
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What intervention should the nurse question for a patient with possible botulism poisoning?
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What has the highest priority for a patient admitted with a C5 spinal cord injury?
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What assessment is most essential for a patient with new onset of Guillain-Barré syndrome?
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Before administering botulinum antitoxin to a patient, what must the nurse do?
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What should the nurse's initial intervention be for a patient with a weak cough effort and crackles after a C7 spinal cord injury?
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Study Notes
Trigeminal Neuralgia
- Major symptom is severe facial pain triggered by light touch or stimulation.
- Assessment for potential complications includes inspecting oral hygiene to prevent conditions like gum disease or dental issues.
- Evaluating treatment outcomes should include asking about the patient’s social interactions since withdrawal is common.
- Nutritional and hydration status monitoring is essential, as acute pain episodes may deter eating.
Bell's Palsy
- Risk factors include type 1 diabetes and herpes simplex infections.
- Symptoms such as pain or herpes lesions near the ear should prompt immediate medical consultation for possible corticosteroid treatment.
- Patients may refuse social interactions due to embarrassment; nurses should respect privacy to ensure adequate nutrition.
Autonomic Hyperreflexia
- Preventive measures include establishing a bowel management plan, as fecal impaction can trigger this condition.
Guillain-Barré Syndrome
- Drooling signifies swallowing difficulties, warranting immediate action to prevent aspiration.
- Essential assessments focus on monitoring respiratory function due to the risk of respiratory failure.
Spinal Cord Injuries
- Neurogenic shock from C6 injuries presents as hypotension and warm extremities.
- Brown-Séquard syndrome results in loss of motor function on the same side as the injury, necessitating careful leg positioning.
- A T2 spinal cord injury retains arm function while potentially diminishing respiratory function.
- A T9 injury can lead to neurogenic reflexic bladder, requiring patient education on intermittent self-catheterization.
Patient Rehabilitation
- C6 injury patients can push wheelchairs but not engage in tasks requiring fine motor control such as driving.
- Involving both the patient and family in rehabilitation planning is critical to foster independence.
Botulism Poisoning
- Maintain NPO status as neuromuscular weakness increases aspiration risk; assess neurologic and respiratory status continuously.
Spinal Tumor Evaluation
- New-onset leg weakness indicates possible spinal cord compression, requiring urgent intervention.
Delegation of Tasks
- Certain nursing actions, such as routine assessments, may be delegated to experienced unlicensed assistive personnel to enhance efficiency in care delivery.### Passive Range of Motion
- Administer passive range of motion exercises to extremities every 4 hours to assist with mobility.
- UAP (Unlicensed Assistive Personnel) education includes assisting with patient movement.
Tetanus Management
- Create a quiet environment for patients with tetanus to prevent painful seizures triggered by noise or bright lights.
- Avoid range-of-motion exercises in tetanus patients to minimize stimulation and the risk of seizures.
Cauda Equina Syndrome Care
- Intermittent catheterization is essential for patients with cauda equina syndrome due to an areflexic bladder.
- Patients will not be able to ambulate and do not require stabilization of the neck after this type of injury.
Prioritizing Patient Assessment
- Assess patients with botulism and difficulty swallowing first, as they may require urgent respiratory intervention.
- Other patient diagnoses like Bell's palsy and neurosyphilis present less immediate threats compared to respiratory distress.
Spinal Cord Tumor Considerations
- Report a decreased ability to move the legs immediately, as this may indicate spinal cord compression, which is a medical emergency.
Sexual Activity Post-Spinal Cord Injury
- Discuss that various options exist for maintaining sexual expression and fertility following a spinal cord injury.
- Reflex erections may be possible, but orgasm could be difficult, depending on the level of the injury.
Nursing Actions for T2 Spinal Cord Injury
- Urinary catheter care, continuous cardiac monitoring, administration of H2 receptor blockers, and maintaining a warm environment are critical.
- Patients are at risk for bradycardia and poikilothermia after T2 spinal cord injuries.
IV Fluid Administration for Neurogenic Shock
- Set the IV pump to deliver lactated Ringer's solution at a rate of 1200 mL/hour to administer 400 mL over 20 minutes.
Emergency Care for C5 Spinal Cord Trauma
- Stabilize the neck and spine first to prevent further injury.
- Administer 100% oxygen using a non-rebreather mask to ensure oxygenation.
- Monitor cardiac rhythm and blood pressure, then infuse normal saline for volume replacement, followed by a CT scan.
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Description
Test your knowledge on spinal cord and peripheral nerve problems as covered in Chapter 60 of Lewis' Medical-Surgical Nursing, 10th Edition. This quiz focuses on key concepts and clinical manifestations related to conditions like trigeminal neuralgia. Assess your understanding and prepare for your nursing assessments with these flashcards.
