Chapter 61 NCLEX Questions Peripheral Nerve and Spinal Cord
1. 1.ID: 809610609
The nurse is caring for a patient admitted with a spinal cord injury following a motor vehicle accident. The patient
exhibits a complete loss of motor, sensory, and reflex activity below the injury level. The nurse recognizes this
condition as which of the following?
A.
Central cord syndrome
B.
Spinal shock syndrome Correct
C.
Anterior cord syndrome
D.
Brown-Séquard 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
reflexes. Brown-Séquard syndrome is characterized by ipsilateral loss of motor function and contralateral loss of
sensory function.
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2. 2.ID: 809610630
Which clinical manifestation would the nurse interpret as a manifestation of neurogenic shock in a patient with acute
spinal cord injury?
A.
Bradycardia Correct
B.
Hypertension
C.
Neurogenic spasticity
D.
Bounding pedal pulses
Neurogenic shock is due to the loss of vasomotor tone caused by injury and is characterized by bradycardia and
hypotension. Loss of sympathetic innervations causes peripheral vasodilation, venous pooling, and a decreased
cardiac output. Thus hypertension, neurogenic spasticity, and bounding pedal pulses are not seen in neurogenic
shock.
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3. 3.ID: 809610620
When planning care for a patient with a C5 spinal cord injury, which nursing diagnosis has the highest priority?
A.
Risk for impairment of tissue integrity caused by paralysis
B.
Altered patterns of urinary elimination caused by tetraplegia
C.
Altered family and individual coping caused by the extent of trauma
D.
Ineffective airway clearance caused by high cervical spinal cord injury Correct
Maintaining a patent airway is the most important goal for a patient with a high cervical fracture. Although all of
these are appropriate nursing diagnoses for a patient with a spinal cord injury, respiratory needs are always the
highest priority. Remember the ABCs.
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4. 4.ID: 809610632
The nurse is providing care for a patient who has been diagnosed with Guillain-Barré syndrome. Which assessment
should be the nurse's priority?
A.
Pain assessment
B.
Glasgow Coma Scale
C.
Respiratory assessment Correct
D.
Musculoskeletal assessment
Although all of the assessments are necessary in the care of patients with Guillain-Barré syndrome, the acute risk of
respiratory failure necessitates vigilant monitoring of the patient's respiratory status.
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5. 5.ID: 809610636
Which manifestations in a patient with a T4 spinal cord injury should alert the nurse to the possibility of autonomic
dysreflexia?
A.
Headache and rising blood pressure Correct
B.
Irregular respirations and shortness of breath
C.
Decreased level of consciousness or hallucinations
D.
Abdominal distention and absence of bowel sounds
Manifestations of autonomic dysreflexia are hypertension (up to 300 mm Hg systolic), a throbbing headache,
bradycardia, and diaphoresis. Respiratory manifestations, decreased level of consciousness, and gastrointestinal
manifestations are not characteristic manifestations.
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6. 6.ID: 809610626
Which intervention should the nurse perform in the acute care of a patient with autonomic dysreflexia?
A.
Urinary catheterization Correct
B.
Administration of benzodiazepines
C.
Suctioning of the patient's upper airway
D.
Placement of the patient in the Trendelenburg position
Because the most common cause of autonomic dysreflexia is bladder irritation, immediate catheterization to relieve
bladder distention may be necessary. Benzodiazepines are contraindicated, and suctioning is likely unnecessary.
The patient should be positioned upright.
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7. 7.ID: 809656644
The patient with peripheral facial paresis on the left side of her face is diagnosed with Bell's palsy. What should the
nurse include in teaching the patient about self-care (select all that apply)?
A.
Administration of antiseizure medications
B.
Preparing for a nerve block to relieve pain
C.
Administration of corticosteroid medications Correct
D.
Dark glasses and artificial tears to protect the eyes Correct
E.
Surgeries available if conservative therapy is not effective
Self-care for Bell's palsy includes corticosteroid medications to decrease inflammation of the facial nerve (CNVII)
and protecting the cornea from drying out because of the inability to close the eyelid. Antiseizure medications, a
nerve block, or surgeries are used for trigeminal neuralgia.
8. 8.ID: 809656648
While on a mission trip, the nurse is caring for a patient diagnosed with tetanus. The patient has been given tetanus
immune globulin (TIG). What should be the focus of collaborative care (select all that apply)?
A.
Administration of penicillin
B.
Tracheostomy for mechanical ventilation Correct
C.
Administration of polyvalent antitoxin
D.
Teach correct processing of canned foods.
E.
Control of spasms with diazepam (Valium) Correct
Control of the spasms of tetanus is essential because the laryngeal and respiratory system spasms cause apnea
and anoxia. A tracheostomy is performed early so mechanical ventilation may be done to maintain ventilation.
Penicillin is administered for neurosyphilis. Use of polyvalent antitoxin and teaching the correct canning process is
done for botulism.
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9. 9.ID: 809610634
After learning about rehabilitation for his spinal cord tumor, which statement shows the patient understands what
rehabilitation is and can do for him?
A.
"I want to be rehabilitated for my daughter's wedding in 2 weeks."
B.
"Rehabilitation will be more work done by me alone to try to get better."
C.
"I will be able to do all my normal activities after I go through rehabilitation."
D.
"With rehabilitation, I will be able to function at my highest level of wellness." Correct
Rehabilitation is an interdisciplinary endeavor carried out with a team approach to teach and enable the patient to
function at the patient's highest level of wellness and adjustment. It will be a lot of work for all involved and take
longer than 2 weeks. With neurologic dysfunction, the patient will not be able to do all the normal activities in the
same way as before the lesion, so this statement should be discussed.
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10. 10.ID: 809656655
A 68-year-old patient with a spinal cord injury has a neurogenic bowel. Beyond the use of bisacodyl (Dulcolax)
suppositories and digital stimulation, which measures should the nurse teach the patient and the caregiver to assist
the patient with bowel evacuation (select all that apply)?
A.
Drink more milk.
B.
Eat 20-30 g of fiber per day. Correct
C.
Use oral laxatives every day.
D.
Drink 1800 to 2800 mL of water or juice. Correct
E.
Establish bowel evacuation time at bedtime.
The patient with a spinal cord injury and neurogenic bowel should eat 20-30 g of fiber and drink 1800 to 2800 mL of
water or juice each day. Milk may cause constipation. Daily oral laxatives may cause diarrhea and are avoided
unless necessary. Bowel evacuation time is usually established 30 minutes after the first meal of the day to take
advantage of the gastrocolic reflex induced by eating.
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11. 11.ID: 809610628
A 25-year-old male patient who is a professional motocross racer has anterior spinal cord syndrome at T10. His
history is significant for tobacco, alcohol, and marijuana use. What is the nurse's priority during rehabilitation?
A.
Prevent urinary tract infections.
B.
Monitor the patient every 15 minutes.
C.
Encourage him to verbalize his feelings. Correct
D.
Teach him about using the gastrocolic reflex.
To help him with his coping and prevent self-harm, the nurse should create a therapeutic patient environment that
encourages his self-expression and verbalization of thoughts and feelings. This patient is at high risk for depression
and self-injury because he is likely to lose function below the umbilicus involving lost motor and sensory function. In
addition, he is a young adult male patient who is likely to need a wheelchair, have impaired sexual function, and is
unlikely to resume his racing career. Because the patient uses tobacco, alcohol, and marijuana frequently,
hospitalization is likely to result in a loss of these habits that can make coping especially difficult for him. Prevention
of urinary tract infections and facilitating bowel evacuation with the gastrocolic reflex will be important but not as
important as helping him cope. In rehabilitation, monitoring every 15 minutes is not needed unless he is on a suicide
watch.
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