Question 1

A 26-year-old patient with a C8 spinal cord injury tells the nurse, "My wife and I have always had a very active sex life, and I am worried that she may leave me if I cannot function sexually." The most appropriate response by the nurse to the patient's comment is to

Accepted Answer

A)  advise the patient to talk to his wife to determine how she feels about his sexual function. 
B)  tell the patient that sildenafil (Viagra) helps to decrease erectile dysfunction in patients with spinal cord injury. 
C)  inform the patient that most patients with upper motor neuron injuries have reflex erections. 
D)  suggest that the patient and his wife work with a nurse specially trained in sexual counseling.

Question 2

As a result of a gunshot wound, a patient has an incomplete right spinal cord lesion at the level of T7, resulting in Brown-Séquard syndrome. Which nursing action should be included in the plan of care?

Accepted Answer

A)  Assessment of the patient for left leg pain 
B)  Assessment of the patient for left arm weakness 
C)  Positioning the patient's right leg when turning the patient 
D)  Teaching the patient to look at the left leg to verify its position

Question 3

The nurse discusses long-range goals with a patient with a C6 spinal cord injury. An appropriate patient outcome is

Accepted Answer

A)  transfers independently to a wheelchair. 
B)  drives a car with powered hand controls. 
C)  turns and repositions self independently when in bed. 
D)  pushes a manual wheelchair on flat, smooth surfaces.

Question 4

When the nurse is planning care for a hospitalized patient who is experiencing an acute episode of trigeminal neuralgia, an appropriate action to include is

Accepted Answer

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 patient.

Question 5

A 25-year-old patient has returned home following extensive rehabilitation for a C8 spinal cord injury. The home care nurse visits and notices that the patient's spouse and parents are performing many of the activities of daily living (ADLs) that the patient had been managing during rehabilitation. The most appropriate action by the nurse at this time is to

Accepted Answer

A)  tell the family members that the patient can perform ADLs independently. 
B)  remind the patient about the importance of independence in daily activities. 
C)  recognize that it is important for the patient's family to be involved in the patient's care and support their activities. 
D)  develop a plan to increase the patient's independence in consultation with the with the patient, spouse, and parents.

Question 6

A patient arrives at an urgent care center with a deep puncture wound after stepping on a nail that was embedded in some old lumber in a field. The patient reports having had a tetanus booster 7 years ago. The nurse will anticipate

Accepted Answer

A)  IV infusion of tetanus immune globulin (TIG). 
B)  initiation of the tetanus-diphtheria immunization series. 
C)  intradermal injection of an immune globulin test dose. 
D)  administration of the tetanus-diphtheria (Td) toxoid booster.

Question 7

The nurse is caring for a patient who is being evaluated for a possible metastatic spinal cord tumor. Which of these data obtained when assessing the patient requires most immediate action by the nurse?

Accepted Answer

A)  The patient has new onset weakness of both legs. 
B)  The patient complains of chronic level 6 pain on a 10-point scale. 
C)  The patient starts to cry and says, "I feel hopeless." 
D)  The patient expresses anxiety about having surgery.

Question 8

A patient with a history of a T2 spinal cord tells the nurse, "I feel awful today. My head is throbbing, and I feel sick to my stomach." Which action should the nurse take first?

Accepted Answer

A)  Notify the patient's health care provider. 
B)  Check the blood pressure (BP). 
C)  Give the ordered antiemetic. 
D)  Assess for a fecal impaction.

Question 9

When caring for a patient who had a C8 spinal cord injury 10 days ago and has a weak cough effort, bibasilar crackles, and decreased breath sounds, the initial intervention by the nurse should be to

Accepted Answer

A)  administer oxygen at 7 to 9 L/min with a face mask. 
B)  place the hands on the epigastric area and push upward when the patient coughs. 
C)  encourage the patient to use an incentive spirometer every 2 hours during the day. 
D)  suction the patient's oral and pharyngeal airway.

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