Chapter 61: Nursing Management: Peripheral Nerve and Spinal Cord Problems Nursing School Test Banks

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

Test Bank

MULTIPLE CHOICE

1. The nurse assessing a 54-year-old female patient with newly diagnosed trigeminal neuralgia will ask the patient about

a.

visual problems caused by ptosis.

b.

triggers leading to facial discomfort.

c.

poor appetite caused by loss of taste.

d.

weakness on the affected side of the face.

ANS: B

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: Apply (application) REF: 1464

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

2. Which action should the nurse take when assessing a patient with trigeminal neuralgia?

a.

Have the patient clench the jaws.

b.

Inspect the oral mucosa and teeth.

c.

Palpate the face to compare skin temperature bilaterally.

d.

Identify trigger zones by lightly touching the affected side.

ANS: B

Oral hygiene is frequently neglected because of fear of triggering facial pain. Having the patient 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: Apply (application) REF: 1465

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

a.

assess whether the patient is doing daily facial exercises.

b.

question whether the patient is using an eye shield at night.

c.

ask the patient about social activities with family and friends.

d.

remind the patient to chew 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 patients 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.

DIF: Cognitive Level: Apply (application) REF: 1464

TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity

4. Which action will the nurse include in the plan of care for a 62-year-old 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: 1464 | 1466

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 Bells palsy. Which information should the nurse include in teaching the patient?

a.

You may be able to prevent Bells palsy by doing facial exercises regularly.

b.

Prophylactic treatment of herpes with antiviral agents prevents Bells palsy.

c.

Medications to treat Bells 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 Bells palsy and rapid corticosteroid treatment may reduce the duration of Bells palsy symptoms. Antiviral therapy for herpes simplex does not reduce the risk for Bells 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 Bells palsy.

DIF: Cognitive Level: Apply (application) REF: 1466

TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

6. A 32-year-old pregnant patient with Bells palsy refuses to eat while others are present because of embarrassment about drooling. The best response by the nurse is to

a.

respect the patients 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 patients concerns with visitors who arrive at mealtimes.

ANS: A

The patients desire for privacy should be respected to encourage adequate nutrition and reduce patient embarrassment. Liquid supplements will reduce the patients enjoyment of the taste of food. It would be inappropriate for the nurse to discuss the patients 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: Apply (application) REF: 1467

TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity

7. Which nursing action will the home health nurse include in the plan of care for a patient with paraplegia at the T4 level in order to prevent autonomic dysreflexia?

a.

Support selection of a high-protein diet.

b.

Discuss options for sexuality and fertility.

c.

Assist in planning a prescribed bowel program.

d.

Use quad coughing to strengthen cough efforts.

ANS: C

Fecal impaction is a common stimulus for autonomic dysreflexia. Dietary protein, coughing, and discussing sexuality/fertility should be included in the plan of care but will not reduce the risk for autonomic dysreflexia.

DIF: Cognitive Level: Apply (application) REF: 1479-1480

TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

8. Which assessment data for a patient who has Guillain-Barr syndrome will require the nurses most immediate action?

a.

The patients triceps reflexes are absent.

b.

The patient is continuously drooling saliva.

c.

The patient complains of severe pain in the feet.

d.

The patients blood pressure (BP) is 150/82 mm Hg.

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, 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-Barr syndrome.

DIF: Cognitive Level: Apply (application) REF: 1468

OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment

MSC: NCLEX: Physiological Integrity

9. A 68-year-old patient hospitalized with a new diagnosis of Guillain-Barr syndrome has numbness and weakness of both feet. The nurse will anticipate teaching the patient about

a.

intubation and mechanical ventilation.

b.

administration of corticosteroid drugs.

c.

insertion of a nasogastric (NG) feeding tube.

d.

infusion of immunoglobulin (Sandoglobulin).

ANS: D

Because the Guillain-Barr 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: 1467

TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

10. A construction worker arrives at an urgent care center with a deep puncture wound after an old nail penetrated his boot.. 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 within 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: 1468

TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

11. The nurse is admitting a patient with a neck fracture at the C6 level to the intensive care unit. Which assessment finding(s) indicate(s) neurogenic shock?

a.

Hyperactive reflex activity below the level of injury

b.

Involuntary, spastic movements of the arms and legs

c.

Hypotension, bradycardia, and warm, pink extremities

d.

Lack of sensation or movement below the level of injury

ANS: C

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: 1470

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-Squard syndrome. Which nursing action should be included in the plan of care?

a.

Assessment of the patient for right arm weakness

b.

Assessment of the patient for increased right leg pain

c.

Positioning the patients left leg when turning the patient

d.

Teaching the patient to look at the right leg to verify its position

ANS: C

The patient with Brown-Squard 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 on the patients 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: 1472

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: 1473

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?

a.

Teach the patient the Cred method.

b.

Instruct the patient how to self-catheterize.

c.

Catheterize for residual urine after voiding.

d.

Assist the patient to the toilet every 2 hours.

ANS: B

Because the patients 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 Cred method is more appropriate for a bladder that is flaccid, such as occurs with areflexic neurogenic bladder. Catheterization after voiding will not resolve the patients incontinence.

DIF: Cognitive Level: Apply (application) REF: 1481

TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

15. When the nurse is developing a rehabilitation plan for a 30-year-old patient with a C6 spinal cord injury, an appropriate goal is that the patient will be able to

a.

drive a car with powered hand controls.

b.

push a manual wheelchair on a flat surface.

c.

turn and reposition independently when in bed.

d.

transfer independently to and from a wheelchair.

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.

DIF: Cognitive Level: Apply (application) REF: 1473

TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

16. A 20-year-old patient who sustained a T2 spinal cord injury 10 days ago angrily 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 best?

a.

Clarify 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 patients 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 patients 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 patients anger. Ignoring the patients comments will increase the patients anger and sense of helplessness.

DIF: Cognitive Level: Apply (application) REF: 1483

TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity

17. A 38-year-old patient has returned home following rehabilitation for a spinal cord injury. The home care nurse notes that the spouse is performing many of the activities that the patient had been managing unassisted during rehabilitation. The most appropriate action by the nurse at this time is to

a.

remind the patient about the importance of independence in daily activities.

b.

tell the spouse to stop because the patient is able to perform activities independently.

c.

develop a plan to increase the patients independence in consultation with the patient and the spouse.

d.

recognize that it is important for the spouse to be involved in the patients care and encourage that participation.

ANS: C

The best action by the nurse will be to involve all the parties in developing an optimal plan of care. Because family members who will be assisting with the patients ongoing care need to feel that 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: 1484

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 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

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: 1468

TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

19. Which nursing action has the highest priority for a patient who was admitted 16 hours previously with a C5 spinal cord injury?

a.

Cardiac monitoring for bradycardia

b.

Assessment of respiratory rate and effort

c.

Application of pneumatic compression devices to legs

d.

Administration of methylprednisolone (Solu-Medrol) infusion

ANS: B

Edema around the area of injury may lead to damage above the C4 level, so the highest priority is assessment of the patients respiratory function. Methylprednisolone (Solu-Medrol) is no longer recommended for the treatment of spinal cord injuries. The other actions also are appropriate but are not as important as assessment of respiratory effort.

DIF: Cognitive Level: Apply (application) REF: 1477

OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment

MSC: NCLEX: Physiological Integrity

20. A 27-year-old patient is hospitalized with new onset of Guillain-Barr syndrome. The most essential assessment for the nurse to carry out is

a.

determining level of consciousness.

b.

checking strength of the extremities.

c.

observing respiratory rate and effort.

d.

monitoring the cardiac rate and rhythm.

ANS: C

The most serious complication of Guillain-Barr 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: Apply (application) REF: 1467-1468

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

a.

obtain the patients temperature.

b.

administer an intradermal test dose.

c.

document the neurologic symptoms.

d.

ask the patient about an allergy to eggs.

ANS: B

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: Apply (application) REF: 1468

OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation

MSC: NCLEX: Physiological Integrity

22. A patient who had a C7 spinal cord injury a week ago has a weak cough effort and audible rhonchi. The initial intervention by the nurse should be to

a.

administer humidified oxygen by mask.

b.

suction the patients mouth and nasopharynx.

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 ability to mobilize secretions. Administration of oxygen will improve oxygenation, but the data do not indicate hypoxemia. The use of the spirometer may improve respiratory status, but the patients 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 nurses first action.

DIF: Cognitive Level: Apply (application) REF: 1477

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.

b.

Give the prescribed analgesic.

c.

Assess the blood pressure (BP).

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 whether autonomic dysreflexia is occurring. Notification of the patients health care provider is appropriate after the BP is obtained. Administration of an antiemetic is indicated after autonomic dysreflexia 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: Apply (application) REF: 1479-1480

OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation

MSC: NCLEX: Physiological Integrity

24. A 39-year-old 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.

c.

The patient starts to cry and says, I feel hopeless.

d.

The patient expresses anxiety about having surgery.

ANS: A

The new onset of symptoms indicates cord compression, which is an emergency that requires rapid treatment to avoid permanent loss of function. The other patient assessments also indicate a need for nursing action but do not require intervention as rapidly as the new onset weakness.

DIF: Cognitive Level: Apply (application) REF: 1485

OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment

MSC: NCLEX: Physiological Integrity

25. Which of these nursing actions for a 64-year-old patient with Guillain-Barr syndrome is most appropriate for the nurse to delegate to an experienced unlicensed assistive personnel (UAP)?

a.

Nasogastric tube feeding q4hr

b.

Artificial tear administration q2hr

c.

Assessment for bladder distention q2hr

d.

Passive range of motion to extremities q4hr

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 scope of practice, and the RN should perform these skills.

DIF: Cognitive Level: Apply (application) REF: 15-16

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 46-year-old patient who develops tetanus from an injectable substance use?

a.

Avoid use of sedatives.

b.

Provide a quiet environment.

c.

Check pupil reaction to light every 4 hours.

d.

Provide range-of-motion exercises several times daily.

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 patients eyes. Range-of-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: 1468

TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

27. Following a cauda equina spinal cord injury, which action will the nurse include in the plan of care?

a.

Catheterize patient every 3 to 4 hours.

b.

Assist patient to ambulate several times daily.

c.

Administer medications to reduce bladder spasm.

d.

Stabilize the neck when repositioning the patient.

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 following a cauda equina injury, which affects the lumbar and sacral nerve roots.

REF: 1472 TOP: Nursing Process: Planning

MSC: NCLEX: Physiological Integrity

28. A nurse who works on the neurology unit just received change-of-shift report. Which patient will the nurse assess first?

a.

Patient with botulism who is experiencing difficulty swallowing

b.

Patient with Bells palsy who has herpes vesicles in front of the ear

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: A

The patients diagnosis and difficulty swallowing indicate that 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: 1468

OBJ: Special Questions: Prioritization; Multiple Patients

TOP: Nursing Process: Assessment MSC: NCLEX: Safe and Effective Care Environment

29. Which finding in a patient with a spinal cord tumor is most important for the nurse to report to the health care provider?

a.

Back pain that increases with coughing

b.

Depression about the diagnosis of a tumor

c.

Decreasing sensation and ability to move the legs

d.

Anxiety about scheduled surgery to remove the tumor

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: 1485

OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment

MSC: NCLEX: Physiological Integrity

30. A 33-year-old patient with a T4 spinal cord injury asks the nurse whether 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

Although sexuality will be changed by the patients 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 patients individual feelings about sexuality.

DIF: Cognitive Level: Apply (application) REF: 1482-1483

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.

Maintain a warm room temperature

e.

Administration of H2 receptor blockers

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. Gastrointestinal (GI) motility is decreased initially and NG suctioning is indicated. 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.

DIF: Cognitive Level: Apply (application) REF: 1477-1479

TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

SHORT ANSWER

1. A patient with neurogenic shock following a spinal cord injury is to receive lactated Ringers solution 500 mL over 30 minutes. When setting the IV pump to deliver the IV fluid, the nurse will set the rate at how many mL/hour?

ANS:

1000

To administer 500 mL in 30 minutes, the nurse will need to set the pump to run at 1000 mL/hour.

DIF: Cognitive Level: Understand (comprehension) REF: 1474

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].)

a. Infuse normal saline at 150 mL/hr.

b. Monitor cardiac rhythm and blood pressure.

c. Administer O2 using a non-rebreather mask.

d. Immobilize the patients 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 patients 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: Apply (application) REF: 1474

OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation

MSC: NCLEX: Physiological Integrity

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