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C60 - Lewis: Medical-Surgical Nursing Practice Questions
Adult/Elder Health I (The College of New Jersey)
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Chapter 60: Spinal Cord and Peripheral Nerve Problems
Lewis: Medical-Surgical Nursing, 10th Edition
MULTIPLE CHOICE
1. The nurse assessing a patient with newly diagnosed trigeminal neuralgia will ask the patient
about
visual problems caused by ptosis.
triggers leading to facial discomfort.
poor appetite caused by loss of taste.
weakness on the affected side of the face.
a.
b.
c.
d.
ANS: B
The major clinical manifestation of trigeminal neuralgia is severe facial pain triggered by
cutaneous stimulation of the nerve. Ptosis, loss of taste, and facial weakness are not
characteristics of trigeminal neuralgia.
DIF: Cognitive Level: Apply (application)
REF:
1437
TOP: Nursing Process: Assessment
MSC: NCLEX: Physiological Integrity
2. Which patient assessment will help the nurse identify potential complications of trigeminal
neuralgia?
Have the patient clench the jaws.
Inspect the oral mucosa and teeth.
Palpate the face to compare skin temperature bilaterally.
Identify trigger zones by lightly touching the affected side.
a.
b.
c.
d.
ANS: B
Oral hygiene is frequently neglected because of fear of triggering facial pain and may lead to
gum disease, dental caries, or an abscess. Having the patient clench the facial muscles will not
be useful because the sensory branches (rather than motor branches) of the nerve are affected
by trigeminal neuralgia. Light touch and palpation may be triggers for pain and should be
avoided.
DIF: Cognitive Level: Apply (application)
REF:
1437
TOP: Nursing Process: Assessment
MSC: NCLEX: Physiological Integrity
3. When evaluating outcomes of a glycerol rhizotomy for a patient with trigeminal neuralgia, the
nurse will
assess if the patient is doing daily facial exercises.
question if the patient is using an eye shield at night.
ask the patient about social activities with family and friends.
remind the patient to chew on the unaffected side of the mouth.
a.
b.
c.
d.
ANS: C
Because withdrawal from social activities is a common manifestation of trigeminal neuralgia,
asking about social activities will help in evaluating if the patient’s symptoms have improved.
Glycerol rhizotomy does not damage the corneal reflex or motor functions of the trigeminal
nerve, so there is no need to use an eye shield, do facial exercises, or take precautions with
chewing.
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DIF: Cognitive Level: Apply (application)
REF:
1438
TOP: Nursing Process: Evaluation
MSC: NCLEX: Physiological Integrity
4. Which action will the nurse include in the plan of care for a patient who is experiencing pain
from trigeminal neuralgia?
a. Assess fluid and dietary intake.
b. Apply ice packs for 20 minutes.
c. Teach facial relaxation techniques.
d. Spend time talking with the patient.
ANS: A
The patient with an acute episode of trigeminal neuralgia may be unwilling to eat or drink, so
assessment of nutritional and hydration status is important. Because stimulation by touch is
the precipitating factor for pain, relaxation of the facial muscles will not improve symptoms.
Application of ice is likely to precipitate pain. The patient will not want to engage in
conversation, which may precipitate attacks.
DIF: Cognitive Level: Apply (application)
REF:
1438
TOP: Nursing Process: Planning
MSC: NCLEX: Physiological Integrity
5. The nurse identifies a patient with type 1 diabetes and a history of herpes simplex infection as
being at risk for Bell’s palsy. Which information should the nurse include in teaching the
patient?
a. “You may be able to prevent Bell’s palsy by doing facial exercises regularly.”
b. “Prophylactic treatment of herpes with antiviral agents prevents Bell’s palsy.”
c. “Medications to treat Bell’s palsy work only if started before paralysis onset.”
d. “Call the doctor if you experience pain or develop herpes lesions near the ear.”
ANS: D
Pain or herpes lesions near the ear may indicate the onset of Bell’s palsy, and rapid
corticosteroid treatment may reduce the duration of Bell’s palsy symptoms. Antiviral therapy
for herpes simplex does not reduce the risk for Bell’s palsy. Corticosteroid therapy will be
most effective in reducing symptoms if started before paralysis is complete but will still be
somewhat effective when started later. Facial exercises do not prevent Bell’s palsy.
DIF: Cognitive Level: Apply (application)
REF:
1440
TOP: Nursing Process: Implementation
MSC: NCLEX: Physiological Integrity
6. A patient with Bell’s palsy refuses to eat while others are present because of embarrassment
about drooling. The best response by the nurse is to
a. respect the patient’s feelings and arrange for privacy at mealtimes.
b. teach the patient to chew food on the unaffected side of the mouth.
c. offer the patient liquid nutritional supplements at frequent intervals.
d. discuss the patient’s concerns with visitors who arrive at mealtimes.
ANS: A
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The patient’s desire for privacy should be respected to encourage adequate nutrition and
reduce patient embarrassment. Liquid supplements may help maintain nutrition but will
reduce the patient’s enjoyment of the taste of food. It would be inappropriate for the nurse to
discuss the patient’s embarrassment with visitors unless the patient wishes to share this
information. Chewing on the unaffected side of the mouth will enhance nutrition and
enjoyment of food but will not decrease the drooling.
DIF: Cognitive Level: Analyze (analysis)
REF: 1440
TOP: Nursing Process: Implementation
MSC: NCLEX: Psychosocial Integrity
7. To prevent autonomic hyperreflexia, which nursing action will the home health nurse include
in the plan of care for a patient who has paraplegia at the T4 level ?
Support selection of a high-protein diet.
Discuss options for sexuality and fertility.
Assist in planning a prescribed bowel program.
Use quad coughing to strengthen cough efforts.
a.
b.
c.
d.
ANS: C
Fecal impaction is a common stimulus for autonomic hyperreflexia. Dietary protein,
coughing, and discussing sexuality and fertility should be included in the plan of care but will
not reduce the risk for autonomic hyperreflexia.
DIF: Cognitive Level: Apply (application)
REF:
1431
TOP: Nursing Process: Planning
MSC: NCLEX: Physiological Integrity
8. Which assessment data for a patient who has Guillain-Barré syndrome will require the nurse’s
most immediate action?
The patient’s sacral area skin is reddened.
The patient is continuously drooling saliva.
The patient complains of severe pain in the feet.
The patient’s blood pressure (BP) is 150/82 mm Hg.
a.
b.
c.
d.
ANS: B
Drooling indicates decreased ability to swallow, which places the patient at risk for aspiration
and requires rapid nursing and collaborative actions such as suctioning and possible
endotracheal intubation. The foot pain should be treated with appropriate analgesics, the BP
requires ongoing monitoring, and the skin integrity requires intervention, but these actions are
not as urgently needed as maintenance of respiratory function.
DIF: Cognitive Level: Analyze (analysis)
REF: 1441
OBJ: Special Questions: Prioritization
TOP: Nursing Process: Assessment
MSC: NCLEX: Physiological Integrity
9. A patient hospitalized with a new diagnosis of Guillain-Barré syndrome has numbness and
weakness of both feet. The nurse will anticipate teaching the patient about
infusion of immunoglobulin
intubation and mechanical ventilation.
administration of corticosteroid drugs.
insertion of a nasogastric (NG) feeding tube.
a.
b.
c.
d.
ANS: D
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Because Guillain-Barré syndrome is in the earliest stages (as evidenced by the symptoms), use
of high-dose immunoglobulin is appropriate to reduce the extent and length of symptoms.
Mechanical ventilation and tube feedings may be used later in the progression of the
syndrome but are not needed now. Corticosteroid use is not helpful in reducing the duration or
symptoms of the syndrome.
DIF: Cognitive Level: Apply (application)
REF:
1441
TOP: Nursing Process: Implementation
MSC: NCLEX: Physiological Integrity
10. A construction worker arrives at an urgent care center with a deep puncture wound from a
rusty nail. The patient reports having had a tetanus booster 6 years ago. The nurse will
anticipate
a. IV infusion of tetanus immune globulin (TIG).
b. administration of the tetanus-diphtheria (Td) booster.
c. intradermal injection of an immune globulin test dose.
d. initiation of the tetanus-diphtheria immunization series.
ANS: B
If the patient has not been immunized in the past 5 years, administration of the Td booster is
indicated because the wound is deep. Immune globulin administration is given by the IM
route if the patient has no previous immunization. Administration of a series of immunization
is not indicated. TIG is not indicated for this patient, and a test dose is not needed for immune
globulin.
DIF: Cognitive Level: Apply (application)
REF:
1442
TOP: Nursing Process: Implementation
MSC: NCLEX: Physiological Integrity
11. The nurse is admitting a patient who has a neck fracture at the C6 level to the intensive care
unit. Which assessment findings indicate neurogenic shock?
Involuntary and spastic movement
Hypotension and warm extremities
Hyperactive reflexes below the injury
Lack of sensation or movement below the injury
a.
b.
c.
d.
ANS: B
Neurogenic shock is characterized by hypotension, bradycardia, and vasodilation leading to
warm skin temperature. Spasticity and hyperactive reflexes do not occur at this stage of spinal
cord injury. Lack of movement and sensation indicate spinal cord injury but not neurogenic
shock.
DIF: Cognitive Level: Understand (comprehension)
REF: 1423
TOP: Nursing Process: Assessment
MSC: NCLEX: Physiological Integrity
12. A patient has an incomplete left spinal cord lesion at the level of T7, resulting in Brown-
Séquard syndrome. Which nursing action should be included in the plan of care?
Assessment of the patient for right arm weakness
Assessment of the patient for increased right leg pain
Positioning the patient’s left leg when turning the patient
Teaching the patient to look at the right leg to verify its position
a.
b.
c.
d.
ANS: C
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The patient with Brown-Séquard syndrome has loss of motor function on the ipsilateral side
and will require the nurse to move the left leg. Pain sensation will be lost in the patient’s right
leg. Arm weakness will not be a problem for a patient with a T7 injury. The patient will retain
position sense for the right leg.
DIF: Cognitive Level: Apply (application)
REF:
1422
TOP: Nursing Process: Implementation
MSC: NCLEX: Physiological Integrity
13. The nurse will explain to the patient who has a T2 spinal cord transection injury that
a. use of the shoulders will be limited.
b. function of both arms should be retained.
c. total loss of respiratory function may occur.
d. tachycardia is common with this type of injury.
ANS: B
The patient with a T2 injury can expect to retain full motor and sensory function of the arms.
Use of only the shoulders is associated with cervical spine injury. Loss of respiratory function
occurs with cervical spine injuries. Bradycardia is associated with injuries above the T6 level.
DIF: Cognitive Level: Understand (comprehension)
REF: 1420
TOP: Nursing Process: Implementation
MSC: NCLEX: Physiological Integrity
14. A patient with paraplegia resulting from a T9 spinal cord injury has a neurogenic reflexic
bladder. Which action will the nurse include in the plan of care?
Teach the patient the Credé method.
Instruct the patient how to self-catheterize.
Catheterize for residual urine after voiding.
Assist the patient to the toilet every 2 hours.
a.
b.
c.
d.
ANS: B
Because the patient’s bladder is spastic and will empty in response to overstretching of the
bladder wall, the most appropriate method is to avoid incontinence by emptying the bladder at
regular intervals through intermittent catheterization. Assisting the patient to the toilet will not
be helpful because the bladder will not empty. The Credé method is more appropriate for a
bladder that is flaccid, such as occurs with areflexic neurogenic bladder. Catheterization after
voiding will not resolve the patient’s incontinence.
DIF: Cognitive Level: Apply (application)
REF:
1433
TOP: Nursing Process: Planning
MSC: NCLEX: Physiological Integrity
15. When the nurse is developing a rehabilitation plan for a 30-yr-old patient with a C6 spinal
cord injury, an appropriate goal is that the patient will be able to
drive a car with powered hand controls.
push a manual wheelchair on a flat surface.
turn and reposition independently when in bed.
transfer independently to and from a wheelchair.
a.
b.
c.
d.
ANS: B
The patient with a C6 injury will be able to use the hands to push a wheelchair on flat, smooth
surfaces. Because flexion of the thumb and fingers is minimal, the patient will not be able to
grasp a wheelchair during transfer, drive a car with powered hand controls, or turn
independently in bed.
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DIF: Cognitive Level: Apply (application)
REF:
1423
TOP: Nursing Process: Planning
MSC: NCLEX: Physiological Integrity
16. A 20-yr-old patient who sustained a T2 spinal cord injury 10 days ago tells the nurse, “I want
to be transferred to a hospital where the nurses know what they are doing.” Which action by
the nurse is appropriate?
a. Respond that abusive language will not be tolerated.
b. Request that the patient provide input for the plan of care.
c. Perform care without responding to the patient’s comments.
d. Reassure the patient about the competence of the nursing staff.
ANS: B
The patient is demonstrating behaviors consistent with the anger phase of the grief process,
and the nurse should allow expression of anger and seek the patient’s input into care.
Expression of anger is appropriate at this stage, and should be accepted by the nurse.
Reassurance about the competency of the staff will not be helpful in responding to the
patient’s concerns. Ignoring the patient’s comments will increase the patient’s anger and sense
of helplessness.
DIF: Cognitive Level: Apply (application)
REF:
1435
TOP: Nursing Process: Implementation
MSC: NCLEX: Psychosocial Integrity
17. A 38-yr-old patient who has had a spinal cord injury returned home following a stay in a
rehabilitation facility. The home care nurse notes the spouse is performing many of the
activities that the patient had been managing unassisted during rehabilitation. The appropriate
nursing action at this phase of rehabilitation is to
a. remind the patient about the importance of independence in daily activities.
b. tell the spouse to stop helping because the patient is able to perform activities
independently.
c. develop a plan to increase the patient’s independence in consultation with the
patient and the spouse.
d. recognize that it is important for the spouse to be involved in the patient’s care and
encourage participation.
ANS: C
The best action by the nurse will be to involve all parties in developing an optimal plan of
care. Because family members who will be assisting with the patient’s ongoing care need to
believe their input is important, telling the spouse that the patient can perform activities
independently is not the best choice. Reminding the patient about the importance of
independence may not change the behaviors of the spouse. Supporting the activities of the
spouse will lead to ongoing dependency by the patient.
DIF: Cognitive Level: Apply (application)
REF:
1432
TOP: Nursing Process: Implementation
MSC: NCLEX: Psychosocial Integrity
18. A patient is admitted with possible botulism poisoning after eating home-canned green beans.
Which intervention ordered by the health care provider will the nurse question?
a. Encourage oral fluids to 3 L/day.
b. Document neurologic symptoms.
c. Position patient lying on the side.
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d. Observe respiratory status closely.
ANS: A
The patient should be maintained on NPO status because neuromuscular weakness increases
risk for aspiration. Side-lying position is not contraindicated. Assessment of neurologic and
respiratory status is appropriate.
DIF: Cognitive Level: Apply (application)
REF:
1442
TOP: Nursing Process: Implementation
MSC: NCLEX: Physiological Integrity
19. Which nursing action has the highest priority for a patient who was admitted 16 hours earlier
with a C5 spinal cord injury?
a. Cardiac monitoring for bradycardia
b. Assessment of respiratory rate and effort
c. Administration of low-molecular-weight heparin
d. Application of pneumatic compression devices to legs
ANS: B
Edema around the area of injury may lead to damage above the C4 level, so the highest
priority is assessment of the patient’s respiratory function. The other actions also are
appropriate for preventing deterioration or complications but are not as important as
assessment of respiratory effort.
DIF: Cognitive Level: Analyze (analysis)
REF: 1429
OBJ: Special Questions: Prioritization
TOP: Nursing Process: Assessment
MSC: NCLEX: Physiological Integrity
20. A patient is hospitalized with new onset of Guillain-Barré syndrome. The most essential
assessment for the nurse to complete is
determining level of consciousness.
checking strength of the extremities.
observing respiratory rate and effort.
monitoring the cardiac rate and rhythm.
a.
b.
c.
d.
ANS: C
The most serious complication of Guillain-Barré syndrome is respiratory failure, and the nurse
should monitor respiratory function continuously. The other assessments will also be included
in nursing care, but they are not as important as respiratory assessment.
DIF: Cognitive Level: Analyze (analysis)
REF: 1441
OBJ: Special Questions: Prioritization
TOP: Nursing Process: Assessment
MSC: NCLEX: Physiological Integrity
21. Before administering botulinum antitoxin to a patient in the emergency department, it is most
important for the nurse to
obtain the patient’s temperature.
administer an intradermal test dose.
document the neurologic symptoms.
ask the patient about an allergy to eggs.
a.
b.
c.
d.
ANS: B
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To assess for possible allergic reactions, an intradermal test dose of the antitoxin should be
administered. Although temperature, allergy history, and symptom assessment and
documentation are appropriate, these assessments will not affect the decision to administer the
antitoxin.
DIF: Cognitive Level: Analyze (analysis)
REF: 1442
OBJ: Special Questions: Prioritization
TOP: Nursing Process: Implementation
MSC: NCLEX: Physiological Integrity
22. A patient who had a C7 spinal cord injury 1 week ago has a weak cough effort and crackles.
The initial intervention by the nurse should be to
a. suction the patient’s nasopharynx.
b. notify the patient’s health care provider.
c. push upward on the epigastric area as the patient coughs.
d. encourage incentive spirometry every 2 hours during the day.
ANS: C
Because the cough effort is poor, the initial action should be to use assisted coughing
techniques to improve the patient’s ability to mobilize secretions. The use of the spirometer
may improve respiratory status, but the patient’s ability to take deep breaths is limited by the
loss of intercostal muscle function. Suctioning may be needed if the patient is unable to expel
secretions by coughing but should not be the nurse’s first action. The health care provider
should be notified if airway clearance interventions are not effective or additional
collaborative interventions are needed.
DIF: Cognitive Level: Analyze (analysis)
REF: 1429
OBJ: Special Questions: Prioritization
TOP: Nursing Process: Implementation
MSC: NCLEX: Physiological Integrity
23. 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. Check for a fecal impaction.
c. Assess the blood pressure (BP).
b. Give the prescribed antiemetic.
d. Notify the health care provider.
ANS: C
The BP should be assessed immediately in a patient with an injury at the T6 level or higher
who complains of a headache to determine if autonomic hyperreflexia is occurring.
Notification of the patient’s health care provider is appropriate after the BP is obtained.
Administration of an antiemetic is indicated if autonomic hyperreflexia is ruled out as the
cause of the nausea. After checking the BP, the nurse may assess for a fecal impaction using
lidocaine jelly to prevent further increased BP.
DIF: Cognitive Level: Analyze (analysis)
REF: 1431
OBJ: Special Questions: Prioritization
TOP: Nursing Process: Implementation
MSC: NCLEX: Physiological Integrity
24. A patient is being evaluated for a possible spinal cord tumor. Which finding by the nurse
requires the most immediate action?
a. The patient has new-onset weakness of both legs.
b. The patient complains of chronic severe back pain.
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c. The patient starts to cry and says, “I feel hopeless.”
d. The patient expresses anxiety about having surgery.
ANS: A
The new symptoms indicate spinal cord compression, an emergency that requires rapid
treatment to avoid permanent loss of function. The other patient assessments also need nursing
action but do not require intervention as rapidly as the new-onset weakness.
DIF: Cognitive Level: Analyze (analysis)
REF: 1437
OBJ: Special Questions: Prioritization
TOP: Nursing Process: Assessment
MSC: NCLEX: Physiological Integrity
25. 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)?
Nasogastric tube feeding q4hr
Artificial tear administration q2hr
Assessment for bladder distention q2hr
Passive range of motion to extremities q4hr
a.
b.
c.
d.
ANS: D
Assisting a patient with movement is included in UAP education and scope of practice.
Administration of tube feedings, administration of ordered medications, and assessment are
skills requiring more education and expanded scope of practice, and the RN should perform
these skills.
DIF: Cognitive Level: Apply (application)
REF:
1441
OBJ: Special Questions: Delegation
TOP: Nursing Process: Implementation
MSC: NCLEX: Safe and Effective Care Environment
26. Which action will the nurse take when caring for a patient who develops tetanus from
injectable substance use?
Avoid use of sedatives.
Provide a quiet environment.
Provide range-of-motion exercises daily.
Check pupil reaction to light every 4 hours.
a.
b.
c.
d.
ANS: B
In patients with tetanus, painful seizures can be precipitated by jarring, loud noises, or bright
lights, so the nurse will minimize noise and avoid shining light into the patient’s eyes. Rangeof-motion exercises may also stimulate the patient and cause seizures. Although the patient
has a history of injectable drug use, sedative medications will be needed to decrease spasms.
DIF: Cognitive Level: Apply (application)
REF:
1442
TOP: Nursing Process: Planning
MSC: NCLEX: Physiological Integrity
27. Which action will the nurse include in the plan of care for a patient who has a cauda equina
spinal cord injury?
Catheterize patient every 3 to 4 hours.
Assist patient to ambulate 4 times daily.
Administer medications to reduce bladder spasm.
Stabilize the neck when repositioning the patient.
a.
b.
c.
d.
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ANS: A
Patients with cauda equina syndrome have areflexic bladder, and intermittent catheterization
will be used for emptying the bladder. Because the bladder is flaccid, antispasmodic
medications will not be used. The legs are flaccid with cauda equina syndrome, and the
patient will be unable to ambulate. The head and neck will not need to be stabilized after a
cauda equina injury, which affects the lumbar and sacral nerve roots.
DIF: Cognitive Level: Apply (application)
REF:
1422
TOP: Nursing Process: Planning
MSC: NCLEX: Physiological Integrity
28. After change-of-shift report on the neurology unit, which patient will the nurse assess first?
a. Patient with Bell’s palsy who has herpes vesicles in front of the ear
b. Patient with botulism who is drooling and experiencing difficulty swallowing
c. Patient with neurosyphilis who has tabes dorsalis and decreased deep tendon
reflexes
d. Patient with an abscess caused by injectable drug use who needs tetanus immune
globulin
ANS: B
The patient’s diagnosis and difficulty swallowing indicate the nurse should rapidly assess for
respiratory distress. The information about the other patients is consistent with their diagnoses
and does not indicate any immediate need for assessment or intervention.
DIF: Cognitive Level: Analyze (analysis)
REF: 1442
OBJ: Special Questions: Prioritization | Special Questions: Multiple Patients
TOP: Nursing Process: Assessment
MSC: NCLEX: Safe and Effective Care Environment
29. Which finding in a patient with a spinal cord tumor requires an immediate report to the health
care provider?
a. Depression about the diagnosis
b. Anxiety about scheduled surgery
c. Decreased ability to move the legs
d. Back pain that worsens with coughing
ANS: C
Decreasing sensation and leg movement indicates spinal cord compression, an emergency that
will require rapid action (such as surgery) to prevent paralysis. The other findings will also
require nursing action but are not emergencies.
DIF: Cognitive Level: Apply (application)
REF:
1436
OBJ: Special Questions: Prioritization
TOP: Nursing Process: Assessment
MSC: NCLEX: Physiological Integrity
30. 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?
a. Reflex erections frequently occur, but orgasm may not be possible.
b. Sildenafil (Viagra) is used by many patients with spinal cord injury.
c. Multiple options are available to maintain sexuality after spinal cord injury.
d. Penile injection, prostheses, or vacuum suction devices are possible options.
ANS: C
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Although sexuality will be changed by the patient’s spinal cord injury, there are options for
expression of sexuality and for fertility. The other information also is correct, but the choices
will depend on the degrees of injury and the patient’s individual feelings about sexuality.
DIF: Cognitive Level: Analyze (analysis)
REF: 1435
OBJ: Special Questions: Prioritization
TOP: Nursing Process: Implementation
MSC: NCLEX: Psychosocial Integrity
MULTIPLE RESPONSE
1. 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)?
a. Urinary catheter care
b. Nasogastric (NG) tube feeding
c. Continuous cardiac monitoring
d. Administration of H2 receptor blockers
e. Maintenance of a warm room temperature
ANS: A, C, D, E
The patient is at risk for bradycardia and poikilothermia caused by sympathetic nervous
system dysfunction and should have continuous cardiac monitoring and maintenance of a
relatively warm room temperature. To avoid bladder distention, a urinary retention catheter is
used during this acute phase. Stress ulcers are a common complication, but can be avoided
through the use of the H2 receptor blockers such as famotidine. Gastrointestinal motility is
decreased initially, and NG suctioning is indicated.
DIF: Cognitive Level: Apply (application)
REF:
1426
TOP: Nursing Process: Planning
MSC: NCLEX: Physiological Integrity
SHORT ANSWER
1. 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?
ANS:
1200
To administer 400 mL in 20 minutes, the nurse will need to set the pump to run at 1200
mL/hour.
DIF: Cognitive Level: Understand (comprehension)
REF: 1420
TOP: Nursing Process: Implementation
MSC: NCLEX: Physiological Integrity
OTHER
1. In which order will the nurse perform the following actions when caring for a patient with
possible C5 spinal cord trauma who is admitted to the emergency department? (Put a comma
and a space between each answer choice [A, B, C, D, E].)
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a. Infuse normal saline at 150 mL/hr.
b. Monitor cardiac rhythm and blood pressure.
c. Administer O2 using a nonrebreather mask.
d. Immobilize the patient’s head, neck, and spine.
e. Transfer the patient to radiology for spinal computed tomography (CT).
ANS:
D, C, B, A, E
The first action should be to prevent further injury by stabilizing the patient’s spinal cord if
the patient does not have penetrating trauma. Maintenance of oxygenation by administration
of 100% O2 is the second priority. Because neurogenic shock is a possible complication,
monitoring of heart rhythm and BP are indicated followed by infusing normal saline for
volume replacement. A CT scan to determine the extent and level of injury is needed once
initial assessment and stabilization are accomplished.
DIF: Cognitive Level: Analyze (analysis)
REF: 1425
OBJ: Special Questions: Prioritization
TOP: Nursing Process: Implementation
MSC: NCLEX: Physiological Integrity
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