Nursing Management: Peripheral Nerve and Spinal Cord Problems

MULTIPLE CHOICE 1. The nurse is assessing a client with newly diagnosed trigeminal neuralgia. Which of the following parameters should the nurse assess? a. Triggers that lead to facial pain b. Visual problems caused by ptosis c. Poor appetite caused by a loss of taste d. Weakness on the affected side of the face ANS: A The major clinical manifestation of trigeminal neuralgia is severe facial pain that is triggered by cutaneous stimulation of the nerve. Ptosis, loss of taste, and facial weakness are not characteristics of trigeminal neuralgia. DIF: Cognitive Level: Application TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity 2. Which of the following actions should the nurse take when assessing a client with trigeminal neuralgia? a. Examine the mouth and teeth thoroughly. b. Have the client 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. ANS: A Oral hygiene is frequently neglected because of fear of triggering facial pain. Having the client clench the facial muscles will not be useful because the sensory 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: Application TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity 3. The nurse is caring for a client with trigeminal neuralgia who has had a glycerol rhizotomy. Which of the following interventions should the nurse implement? a. Ask whether the client is using an eye shield at night. b. Determine whether the client is doing daily facial exercises. c. Question the client about social activities with family and friends. d. Remind the client to chew food on the unaffected side of the mouth. ANS: C Because withdrawal from social activities is a common manifestation of trigeminal neuralgia, asking about social activities will help in evaluating whether the client’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. NURSINGTB.COM Medical-Surgical Nursing in Canada 4th Edition Lewi Test Bank NURSING MANAGEMENT : PERIPHERAL NERVE AND SPINE CORD PROBLEMS NU RS IN GT B.CO M DIF: Cognitive Level: Application TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity 4. Which of the following actions should the nurse include in the plan of care when caring for a client who is experiencing trigeminal neuralgia? a. Teach facial and jaw relaxation techniques. b. Assess intake and output and dietary intake. c. Apply ice packs for no more than 20 minutes. d. Spend time at the bedside talking with the client. ANS: B The client 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 client will not want to engage in conversation, which may precipitate attacks. DIF: Cognitive Level: Application TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity 5. The nurse is teaching a client who is at risk for Bell’s palsy because of previous herpes simplex infection. Which of the following information should the nurse include? a. “Call the doctor if pain or herpes lesions occur near the ear.” b. “Treatment of herpes with antiviral agents prevents Bell’s palsy.” c. “You may be able to prevent Bell’s palsy by doing facial exercises regularly.” d. “Medications to treat Bell’s palsy work only if started before paralysis onset.” ANS: A 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: Application TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 6. The nurse is caring for a client with Bell’s palsy who refuses to eat while others are present because of embarrassment about drooling. Which of the following responses is best for the nurse to do? a. Respect the client’s desire and arrange for privacy at mealtimes. b. Teach the client to chew food on the unaffected side of the mouth. c. Offer the client liquid nutritional supplements at frequent intervals. d. Discuss the client’s concerns with visitors who arrive at mealtimes. ANS: A The client’s desire for privacy should be respected to encourage adequate nutrition and reduce client embarrassment. Liquid supplements will reduce the client’s enjoyment of the taste of food. It would be inappropriate for the nurse to discuss the client’s embarrassment with visitors unless the client 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. NURSINGTB.COM Medical-Surgical Nursing in Canada 4th Edition Lewi Test Bank NU RS IN GT B.CO M DIF: Cognitive Level: Application TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity 7. Which of the following nursing actions should the home health nurse include in the plan of care for a client with paraplegia in order to prevent autonomic dysreflexia? a. Assist with selection of a high protein diet. b. Use quad coughing to assist cough effort. c. Discuss options for sexuality and fertility. d. Teach the purpose of a prescribed bowel program. ANS: D Fecal impaction is a common stimulus for autonomic dysreflexia. The other actions may be included in the plan of care but will not reduce the risk for autonomic dysreflexia. DIF: Cognitive Level: Application TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity 8. The nurse is caring for a client who has Guillain-Barré syndrome. Which of the following assessment data obtained by the nurse will require the most immediate action? a. The client has continuous drooling of saliva. b. The client’s blood pressure (BP) is 106/50 mm Hg. c. The client’s quadriceps and triceps reflexes are absent. d. The client complains of severe tingling pain in the feet. ANS: A Drooling indicates decreased ability to swallow, which places the client 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, and the BP requires ongoing monitoring, but these actions are not as urgently needed as maintenance of respiratory function. Absence of the reflexes should be documented, but this is a common finding in Guillain-Barré syndrome. DIF: Cognitive Level: Application TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity 9. The nurse is caring for a client who has numbness and weakness of both feet and who is hospitalized with Guillain-Barré syndrome. Which of the following information should the nurse include in the client’s plan of care? a. Intubation and mechanical ventilation b. Administration of IV corticosteroid drugs c. Insertion of a nasogastric (NG) feeding tube d. IV infusion of high dose immunoglobulin (IVIG) ANS: D Because the 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: Application TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity NURSINGTB.COM Medical-Surgical Nursing in Canada 4th Edition Lewi Test Bank NU RS IN GT B.CO M 10. A client arrives at an urgent care centre with a deep puncture wound after stepping on a nail that was lying on the ground. The client reports having had a tetanus booster 7 years ago. Which of the following actions should the nurse 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 client has not been immunized within 5 years and presents with an open wound, administration of the Td booster is indicated because the wound is deep. Immune globulin administration is given by the IM route if the client has no previous immunization. Administration of a series of immunization is not indicated. TIG is not indicated for this client, and a test dose is not needed for immune globulin. DIF: Cognitive Level: Application TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 11. The nurse is caring for a client with a neck fracture at the C5 level in the intensive care unit. During initial assessment of the client, the nurse recognizes the presence of neurogenic shock upon assessing which of the following findings? a. Hypotension, bradycardia, and warm extremities b. Involuntary, spastic movements of the arms and legs c. Hyperactive reflex activity below the level of the injury d. Lack of movement or sensation below the level of the injury ANS: A 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 or sensation indicates spinal cord injury, but not neurogenic shock. DIF: Cognitive Level: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity 12. The nurse is caring for a client who has an incomplete right spinal cord lesion at the level of T7, resulting in Brown-Séquard syndrome. Which of the following nursing actions should be included in the plan of care? a. Assessment of the client for left leg pain b. Assessment of the client for left arm weakness c. Positioning the client’s right leg when turning the client d. Teaching the client to look at the left leg to verify its position ANS: C The client with Brown-Séquard syndrome has loss of motor function on the ipsilateral side and will require the nurse to move the right leg. Pain sensation will be lost on the client’s left leg. Left arm weakness will not be a problem for a client with a T7 injury. The client will retain position sense for the left leg. DIF: Cognitive Level: Application TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity NURSINGTB.COM Medical-Surgical Nursing in Canada 4th Edition Lewi Test Bank NU RS IN GT B.CO M 13. The nurse is caring for a client with a T1 spinal cord injury in the intensive care unit. Which of the following information should the nurse include in the teaching plan for the client and family? a. Use of the shoulders will be preserved. b. Full function of the client’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. ANS: B The client with a T1 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: Comprehension TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 14. The nurse is caring for a client with paraplegia resulting from a T10 spinal cord injury who has a neurogenic reflex bladder. Which of the following actions should the nurse include in the plan of care? a. Educate on the use of the Credé method. b. Teach the client how to self-catheterize. c. Catheterize for residual urine after voiding. d. Assist the client to the toilet every 2 hours. ANS: B Because the client’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 client 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 a reflexic neurogenic bladder. Catheterization after voiding will not resolve the client’s incontinence. DIF: Cognitive Level: Application TOP: Nursing Process: Plannin