front 1 The nurse is caring for a client with spinal cord injury (SCI) who is participating in a bowel retraining program. What would the nurse anticipate to promote during the bowel retraining program? 1.Sufficiently low water content in the stool 2.Low intestinal roughage that promotes easier digestion 3.Constriction of the anal sphincter based on voluntary control 4.Stimulation of the parasympathetic reflex center at the S1 to S4 level in the spinal cord | back 1 4.Stimulation of the parasympathetic reflex center at the S1 to S4 level in the spinal cord |
front 2 A client with a spinal cord injury is prone to experiencing autonomic dysreflexia. The nurse would include which measures in the plan of care to minimize the risk of occurrence? Select all that apply. 1.Keeping the linens wrinkle-free under the client 2.Preventing unnecessary pressure on the lower limbs 3.Limiting bladder catheterization to once every 12 hours 4.Turning and repositioning the client at least every 2 hours 5.Ensuring that the client has a bowel movement at least once a week | back 2 1.Keeping the linens wrinkle-free under the client 2.Preventing unnecessary pressure on the lower limbs 4.Turning and repositioning the client at least every 2 hours |
front 3 The nurse is evaluating the neurological signs of a client in spinal shock following spinal cord injury. Which observation indicates that spinal shock persists? 1.Hyperreflexia 2.Positive reflexes 3.Flaccid paralysis 4.Reflex emptying of the bladder | back 3 3.Flaccid paralysis |
front 4 A client with a spinal cord injury at the level of C5 has a weakened respiratory effort and ineffective cough and is using accessory neck muscles in breathing. The nurse carefully monitors the client and suspects the presence of which problem? 1.Altered breathing pattern 2.Increased likelihood of injury 3.Ineffective oxygen consumption 4.Increased susceptibility to aspiration | back 4 1.Altered breathing pattern |
front 5 A client with a spinal cord injury becomes angry and belligerent whenever the nurse tries to administer care. The nurse would perform which action? 1.Ask the family to deliver the care. 2.Leave the client alone until ready to participate. 3.Advise the client that rehabilitation progresses more quickly with cooperation. 4.Acknowledge the client's anger and continue to encourage participation in care. | back 5 4.Acknowledge the client's anger and continue to encourage participation in care. |
front 6 The nurse is caring for a client who sustained a spinal cord injury. During administration of morning care, the client begins to exhibit signs and symptoms of autonomic dysreflexia. Which initial nursing action would the nurse take? 1.Elevate the head of the bed. 2.Examine the rectum digitally. 3.Assess the client's blood pressure. 4.Place the client in the prone position. | back 6 1.Elevate the head of the bed. |
front 7 The home care nurse is making a visit to a client who requires use of a wheelchair after a spinal cord injury sustained 4 months earlier. Just before leaving the home, the nurse ensures that which intervention has been done to prevent an episode of autonomic dysreflexia (hyperreflexia)? 1.Updating the home safety sheet 2.Leaving the client in an unchilled area of the room 3.Noting a bowel movement on the client progress note 4.Recording the amount of urine obtained with catheterization | back 7 2.Leaving the client in an unchilled area of the room |
front 8 A client who has a spinal cord injury that resulted in paraplegia experiences a sudden onset of severe headache and nausea. The client is diaphoretic with piloerection and has flushing of the skin. The client's systolic blood pressure (BP) is 210 mm Hg. What would the nurse immediately suspect? 1.Return of spinal shock 2.Malignant hypertension 3.Impending brain attack (stroke) 4.Autonomic dysreflexia (hyperreflexia) | back 8 4.Autonomic dysreflexia (hyperreflexia) |
front 9 The nurse is caring for a client who is brought to the hospital emergency department with a spinal cord injury. The nurse minimizes the risk of compounding the injury by performing which action? 1.Keeping the client on a stretcher 2.Logrolling the client onto a soft mattress 3.Logrolling the client onto a firm mattress 4.Placing the client on a bed that provides spinal immobilization | back 9 4.Placing the client on a bed that provides spinal immobilization |
front 10 A client with a spinal cord injury expresses little interest in food and is very particular about the choice of meals that are actually eaten. How would the nurse interpret this information? 1.Anorexia is a sign of clinical depression, and a referral to a psychologist is needed. 2.The client has compulsive habits that need to be ignored as long as they are not harmful. 3.The client probably has a naturally slow metabolism, and the decreased nutritional intake will not matter. 4.Meal choices represent an area of client control and need to be encouraged as much as is nutritionally reasonable. | back 10 4.Meal choices represent an area of client control and need to be encouraged as much as is nutritionally reasonable. |
front 11 The nurse is teaching a client with paraplegia from a spinal cord injury measures to maintain skin integrity. Which instruction will be most helpful to the client? 1.Shift weight every 2 hours while in a wheelchair. 2.Change bedsheets every other week to maintain cleanliness. 3.Place a pillow on the seat of the wheelchair to provide extra comfort. 4.Use a mirror to inspect for redness and skin breakdown twice a week. | back 11 1.Shift weight every 2 hours while in a wheelchair. |
front 12 The nurse is performing an assessment on a client with the diagnosis of Brown-Séquard syndrome. The nurse would expect to note which assessment finding? 1.Bilateral loss of pain and temperature sensation 2.Ipsilateral paralysis and loss of touch and vibration 3.Contralateral paralysis and loss of touch, pressure, and vibration 4.Complete paraplegia or quadriplegia, depending on the level of injury | back 12 2.Ipsilateral paralysis and loss of touch and vibration |
front 13 A client admitted to the nursing unit from the hospital emergency department has a C4 spinal cord injury. In conducting the admission assessment, what is the nurse's priority action? 1.Take the temperature. 2.Listen to breath sounds. 3.Observe for dyskinesias. 4.Assess extremity muscle strength. | back 13 2.Listen to breath sounds. |
front 14 The client with a cervical spine injury has cervical tongs applied in the emergency department. What would the nurse include when planning care for this client? Select all that apply. 1.Using a RotoRest bed 2.Ensuring that weights hang freely 3.Removing the weights to reposition the client 4.Assessing the integrity of the weights and pulleys 5.Comparing the amount of prescribed traction with the amount in use | back 14 1.Using a RotoRest bed 2.Ensuring that weights hang freely 4.Assessing the integrity of the weights and pulleys 5.Comparing the amount of prescribed traction with the amount in use |
front 15 The nurse is caring for the client who suffered a spinal cord injury 48 hours ago. What would the nurse assess for when monitoring for gastrointestinal complications? 1.A history of diarrhea 2.A flattened abdomen 3.Hyperactive bowel sounds 4.Hematest-positive nasogastric tube drainage | back 15 4.Hematest-positive nasogastric tube drainage |
front 16 The client with a spinal cord injury at the level of T4 is experiencing a severe throbbing headache with a blood pressure of 180/100 mm Hg. What is the priority nursing intervention? 1.Notify the neurologist 2.Loosen tight clothing on the client. 3.Place the client in a sitting position. 4.Check the urinary catheter tubing for kinks or obstruction. | back 16 3.Place the client in a sitting position. |
front 17 The family of a client with a spinal cord injury rushes to the nursing station, saying that the client needs immediate help. On entering the room, the nurse notes that the client is diaphoretic with a flushed face and neck and is complaining of a severe headache. The pulse rate is 40 beats/minute, and the blood pressure is 230/100 mm Hg. The nurse acts quickly, suspecting that the client is experiencing which condition? 1.Spinal shock 2.Pulmonary embolism 3.Autonomic dysreflexia 4.Malignant hyperthermia | back 17 3.Autonomic dysreflexia |
front 18 A client with a spinal cord injury suddenly experiences an episode of autonomic dysreflexia. After checking the client's vital signs, the nurse takes the following actions. Arrange the actions in the order they would be performed. All options must be used. 1.Raise the head of the bed. 2.Check for bladder distention. 3.Contact the primary health care provider (PHCP). 4.Loosen tight clothing on the client. 5.Administer an antihypertensive medication. 6.Document the occurrence, treatment, and response. | back 18 1.Raise the head of the bed. 4.Loosen tight clothing on the client. 2.Check for bladder distention. 3.Contact the primary health care provider (PHCP). 5.Administer an antihypertensive medication. 6.Document the occurrence, treatment, and response. |
front 19 A client is admitted to the hospital with a diagnosis of neurogenic shock after a traumatic motor vehicle collision. Which manifestation best characterizes this diagnosis? 1.Bradycardia 2.Hyperthermia 3.Hypoglycemia 4.Increased cardiac output | back 19 1.Bradycardia |
front 20 The nursing student develops a plan of care for a client with a spinal cord injury with paraplegia who is at risk for injury related to spasticity of the leg muscles. On reviewing the student's plan, the nurse identifies which action as an incorrect intervention? 1.Using prescribed muscle relaxants as needed 2.Using padded restraints to immobilize the limb 3.Performing range-of-motion exercises to the affected limbs 4.Removing potentially harmful objects near the spastic limbs | back 20 2.Using padded restraints to immobilize the limb |
front 21 Dantrolene is prescribed for a client with spinal cord injury for discomfort caused by spasticity. Which finding would alert the nurse to a potential adverse effect associated with this medication? 1.Headache 2.Blurred vision 3.Elevated temperature 4.Abdominal distention | back 21 3.Elevated temperature |
front 22 The primary health care provider is planning to administer a skeletal muscle relaxant to a client with a spinal cord injury. The medication will be administered intrathecally. Which medication would the nurse expect to be prescribed and administered by this route? 1.Baclofen 2.Chlorzoxazone 3.Dantrolene sodium 4.Cyclobenzaprine hydrochloride | back 22 1.Baclofen |
front 23 A client with a history of spinal cord injury is beginning medication therapy with baclofen. The nurse determines that the client understands the side/adverse effects of the medication if the client makes which statement? 1."The medication may make me drowsy." 2."The medication can cause high blood pressure." 3."The medication may cause me to have some muscle pain." 4."The medication may increase my sensitivity to bright light." | back 23 1."The medication may make me drowsy." |
front 24 A client experiencing spasticity as a result of spinal cord injury has a new prescription for dantrolene. Before administering the first dose, the nurse checks to see whether which baseline study has been done? 1.Liver function studies 2.Renal function studies 3.Otoscopic examination 4.Blood glucose measurements | back 24 1.Liver function studies |
front 25 Dantrolene sodium has been administered to a client with a spinal cord injury. The nurse determines that the client is experiencing an adverse effect of the medication if which is noted? 1.Dizziness 2.Drowsiness 3.Abdominal pain 4.Light-headedness | back 25 3.Abdominal pain |
front 26 The nurse has received the client assignment for the day. Which client would the nurse care for first? 1.A client asking to leave against medical advice (AMA) 2.A client who is a fall risk and needs assistance to the bathroom 3.A client needing medication before breakfast because it is a timed dose 4.A client recently admitted after a motor vehicle accident still in cervical spine precautions | back 26 4.A client recently admitted after a motor vehicle accident still in cervical spine precautions |