Question 1

A nurse assesses a client who is recovering from a diskectomy 6 hours ago.Which assessment finding should the nurse address first?

Accepted Answer

A)   Sleepy but arouses to voice
B)   Dry and cracked oral mucosa
C)   Pain present in lower back
D)   Bladder palpated above pubis D

Question 2

A nurse is teaching a client with multiple sclerosis who is prescribed cyclophosphamide (Cytoxan)and methylprednisolone (Medrol).Which statement should the nurse include in this client's discharge teaching?

Accepted Answer

A)   "Take warm baths to promote muscle relaxation."
B)   "Avoid crowds and people with colds."
C)   "Relying on a walker will weaken your gait."
D)   "Take prescribed medications when symptoms occur." B

Question 3

A nurse teaches a client with a lower motor neuron lesion who wants to achieve bladder control.Which statement should the nurse include in this client's teaching?

Accepted Answer

A)   "Stroke the inner aspect of your thigh to initiate voiding."
B)   "Use a clean technique for intermittent catheterization."
C)   "Implement digital anal stimulation when your bladder is full."
D)   "Tighten your abdominal muscles to stimulate urine flow." D

Question 4

A nurse assesses a client with early-onset multiple sclerosis (MS).Which clinical manifestation should the nurse expect to find?

Accepted Answer

A)   Hyperresponsive reflexes
B)   Excessive somnolence
C)   Nystagmus
D)   Heat intolerance

Question 5

A nurse assesses the health history of a client who is prescribed ziconotide (Prialt)for chronic back pain.Which assessment question should the nurse ask?

Accepted Answer

A)   "Are you taking a nonsteroidal anti-inflammatory drug?"
B)   "Do you have a mental health disorder?"
C)   "Are you able to swallow medications?"
D)   "Do you smoke cigarettes or any illegal drugs?"

Question 6

After teaching a client with a spinal cord injury,the nurse assesses the client's understanding.Which client statement indicates a correct understanding of how to prevent respiratory problems at home?

Accepted Answer

A)   "I'll use my incentive spirometer every 2 hours while I'm awake."
B)   "I'll drink thinned fluids to prevent choking."
C)   "I'll take cough medicine to prevent excessive coughing."
D)   "I'll position myself on my right side so I don't aspirate."

Question 7

A nurse cares for several clients on a neurologic unit.Which prescription for a client should direct the nurse to ensure that an informed consent has been obtained before the test or procedure?

Accepted Answer

A)   Sensation measurement via the pinprick method
B)   Computed tomography of the cranial vault
C)   Lumbar puncture for cerebrospinal fluid sampling
D)   Venipuncture for autoantibody analysis

Question 8

A nurse teaches a client who is recovering from a spinal fusion.Which statement should the nurse include in this client's postoperative instructions?

Accepted Answer

A)   "Only lift items that are 10 pounds or less."
B)   "Wear your brace whenever you are out of bed."
C)   "You must remain in bed for 3 weeks after surgery."
D)   "You are prescribed medications to prevent rejection."

Question 9

A nurse cares for a client with a spinal cord injury.With which interdisciplinary team member should the nurse consult to assist the client with activities of daily living?

Accepted Answer

A)   Social worker
B)   Physical therapist
C)   Occupational therapist
D)   Case manager

Question 10

An emergency department nurse cares for a client who experienced a spinal cord injury 1 hour ago.Which prescribed medication should the nurse prepare to administer?

Accepted Answer

A)   Intrathecal baclofen (Lioresal) 
B)   Methylprednisolone (Medrol) 
C)   Atropine sulfate
D)   Epinephrine (Adrenalin)

Question 11

A nurse assesses a client who is recovering from anterior cervical diskectomy and fusion.Which complication should alert the nurse to urgently communicate with the health care provider?

Accepted Answer

A)   Auscultated stridor
B)   Weak pedal pulses
C)   Difficulty swallowing
D)   Inability to shrug shoulders

Question 12

A nurse cares for a client with amyotrophic lateral sclerosis (ALS).The client states,"I do not want to be placed on a mechanical ventilator." How should the nurse respond?

Accepted Answer

A)   "You should discuss this with your family and health care provider."
B)   "Why are you afraid of being placed on a breathing machine?"
C)   "Using the incentive spirometer each hour will delay the need for a ventilator."
D)   "What would you like to be done if you begin to have difficulty breathing?"

Question 13

An emergency room nurse initiates care for a client with a cervical spinal cord injury who arrives via emergency medical services.Which action should the nurse take first?

Accepted Answer

A)   Assess level of consciousness.
B)   Obtain vital signs.
C)   Administer oxygen therapy.
D)   Evaluate respiratory status.

Question 14

A nurse plans care for a client with a halo fixator.Which interventions should the nurse include in this client's plan of care? (Select all that apply.)

Accepted Answer

A)   Tape a halo wrench to the client's vest.
B)   Assess the pin sites for signs of infection.
C)   Loosen the pins when sleeping.
D)   Decrease the client's oral fluid intake.
E)   Assess the chest and back for skin breakdown.

Question 15

A nurse promotes the prevention of lower back pain by teaching clients at a community center.Which instruction should the nurse include in this education?

Accepted Answer

A)   "Participate in an exercise program to strengthen muscles."
B)   "Purchase a mattress that allows you to adjust the firmness."
C)   "Wear flat instead of high-heeled shoes to work each day."
D)   "Keep your weight within 20% of your ideal body weight."

Question 16

A nurse cares for a client who presents with an acute exacerbation of multiple sclerosis (MS).Which prescribed medication should the nurse prepare to administer?

Accepted Answer

A)   Baclofen (Lioresal) 
B)   Interferon beta-1b (Betaseron) 
C)   Dantrolene sodium (Dantrium) 
D)   Methylprednisolone (Medrol)

Question 17

A nurse assesses a client who is recovering from a lumbar laminectomy.Which complications should alert the nurse to urgently communicate with the health care provider? (Select all that apply.)

Accepted Answer

A)   Surgical discomfort
B)   Redness and itching at the incision site
C)   Incisional bulging
D)   Clear drainage on the dressing
E)   Sudden and severe headache

Question 18

A nurse assesses clients at a community center.Which client is at greatest risk for lower back pain?

Accepted Answer

A)   A 24-year-old female who is 25 weeks pregnant
B)   A 36-year-old male who uses ergonomic techniques
C)   A 45-year-old male with osteoarthritis
D)   A 53-year-old female who uses a walker

Question 19

A nurse cares for a client with a lower motor neuron injury who is experiencing a flaccid bowel elimination pattern.Which actions should the nurse take to assist in relieving this client's constipation? (Select all that apply.)

Accepted Answer

A)   Pour warm water over the perineum.
B)   Provide a diet high in fluids and fiber.
C)   Administer daily tap water enemas.
D)   Implement a consistent daily time for elimination.
E)   Massage the abdomen from left to right.F)  Perform manual disimpaction.

Question 20

After teaching a male client with a spinal cord injury at the T4 level,the nurse assesses the client's understanding.Which client statements indicate a correct understanding of the teaching related to sexual effects of this injury? (Select all that apply.)

Accepted Answer

A)   "I will explore other ways besides intercourse to please my partner."
B)   "I will not be able to have an erection because of my injury."
C)   "Ejaculation may not be as predictable as before."
D)   "I may urinate with ejaculation but this will not cause infection."
E)   "I should be able to have an erection with stimulation."

Exam 43: Care of Patients with Problems of the Central Nervous System: The Spinal Cord