Chapter 60: Spinal Cord and Peripheral
Nerve Problems Lewis: Medical-Surgical
Nursing, 10th Edition
A 20-12 months-old affected person who sustained a T2 spinal twine damage 10 days ago tells
the nurse, "I want to be transferred to a medical institution in which the nurses know what they
are doing." Which action through the nurse is appropriate?
A. Respond that abusive language will not be tolerated.
B. Request that the affected person offer enter for the plan of care.
C. Perform care without responding to the patient's remarks.
D. Reassure the patient approximately the competence of the nursing group of workers. -
ANS-ANS: B
The patient is demonstrating behaviors constant with the anger segment of the grief procedure,
and the nurse must allow expression of anger and are seeking for the patient's input into care.
Expression of anger is appropriate at this level, and have to be widely wide-spread with the aid
of the nurse. Reassurance about the competency of the personnel will no longer be useful in
responding to the patient's issues. Ignoring the affected person's remarks will boom the patient's
anger and feel of helplessness.
DIF: Cognitive Level: Apply (utility)
A 38-yr-old patient who has had a spinal twine harm back domestic following a live in a
rehabilitation facility. The domestic care nurse notes the spouse is appearing many of the sports
that the affected person had been managing unassisted in the course of rehabilitation. The
appropriate nursing action at this segment of rehabilitation is to
a. Remind the affected person approximately the significance of independence in every day
sports.
B. Inform the partner to prevent helping due to the fact the affected person is able to carry out
activities independently.
C. Broaden a plan to boom the patient's independence in consultation with the patient and the
partner.
D. Recognize that it is essential for the partner to be worried within the affected person's care
and inspire participation. - ANS-ANS: C
The fine motion via the nurse can be to involve all events in developing an optimum plan of
care. Because own family individuals who could be helping with the affected person's ongoing
care need to believe their enter is crucial, telling the spouse that the patient can perform sports
independently isn't always the high-quality choice. Reminding the affected person about the
importance of independence won't change the behaviors of the partner. Supporting the sports of
the spouse will lead to ongoing dependency by way of the patient.
, DIF: Cognitive Level: Apply (utility)
A production worker arrives at an urgent care center with a deep puncture wound from a rusty
nail. The patient reports having had a tetanus booster 6 years in the past. The nurse will
anticipate
a. IV infusion of tetanus immune globulin (TIG).
B. Management of the tetanus-diphtheria (Td) booster.
C. Intradermal injection of an immune globulin test dose.
D. Initiation of the tetanus-diphtheria immunization collection. - ANS-ANS: B
If the affected person has now not been immunized inside the beyond five years, management
of the Td booster is indicated because the wound is deep. Immune globulin administration is
given via the IM direction if the affected person has no preceding immunization. Administration
of a sequence of immunization is not indicated. TIG is not indicated for this patient, and a take a
look at dose isn't wanted for immune globulin.
DIF: Cognitive Level: Apply (software)
A patient admitted with dermal ulcers who has a records of a T3 spinal wire injury tells the
nurse, "I have a pounding headache and I experience sick to my belly." Which motion ought to
the nurse take first?
A. Check for a fecal impaction. C. Assess the blood pressure (BP).
B. Give the prescribed antiemetic. D. Notify the fitness care provider. - ANS-ANS: C
The BP must be assessed immediately in a affected person with an injury on the T6 degree or
higher who complains of a headache to determine if autonomic hyperreflexia is going on.
Notification of the patient's health care company is suitable after the BP is acquired.
Administration of an antiemetic is indicated if autonomic hyperreflexia is dominated out because
the cause of the nausea. After checking the BP, the nurse can also assess for a fecal impaction
using lidocaine jelly to prevent similarly multiplied BP.
DIF: Cognitive Level: Analyze (analysis)
A patient has an incomplete left spinal cord lesion at the level of T7, resulting in Brown-Séquard
syndrome. Which nursing motion should be included inside the plan of care?
A. Assessment of the patient for right arm weakness
b. Assessment of the affected person for expanded right leg pain
c. Positioning the patient's left leg while turning the affected person
d. Teaching the affected person to take a look at the right leg to verify its function - ANS-ANS: C
The affected person with Brown-Séquard syndrome has loss of motor feature on the ipsilateral
facet and will require the nurse to transport the left leg. Pain sensation will be misplaced inside
the affected person's proper leg. Arm weakness will now not be a trouble for a affected person
with a T7 damage. The affected person will keep function experience for the proper leg.
DIF: Cognitive Level: Apply (software)
A patient hospitalized with a new analysis of Guillain-Barré syndrome has numbness and weak
spot of each feet. The nurse will anticipate coaching the affected person about
a. Infusion of immunoglobulin
Nerve Problems Lewis: Medical-Surgical
Nursing, 10th Edition
A 20-12 months-old affected person who sustained a T2 spinal twine damage 10 days ago tells
the nurse, "I want to be transferred to a medical institution in which the nurses know what they
are doing." Which action through the nurse is appropriate?
A. Respond that abusive language will not be tolerated.
B. Request that the affected person offer enter for the plan of care.
C. Perform care without responding to the patient's remarks.
D. Reassure the patient approximately the competence of the nursing group of workers. -
ANS-ANS: B
The patient is demonstrating behaviors constant with the anger segment of the grief procedure,
and the nurse must allow expression of anger and are seeking for the patient's input into care.
Expression of anger is appropriate at this level, and have to be widely wide-spread with the aid
of the nurse. Reassurance about the competency of the personnel will no longer be useful in
responding to the patient's issues. Ignoring the affected person's remarks will boom the patient's
anger and feel of helplessness.
DIF: Cognitive Level: Apply (utility)
A 38-yr-old patient who has had a spinal twine harm back domestic following a live in a
rehabilitation facility. The domestic care nurse notes the spouse is appearing many of the sports
that the affected person had been managing unassisted in the course of rehabilitation. The
appropriate nursing action at this segment of rehabilitation is to
a. Remind the affected person approximately the significance of independence in every day
sports.
B. Inform the partner to prevent helping due to the fact the affected person is able to carry out
activities independently.
C. Broaden a plan to boom the patient's independence in consultation with the patient and the
partner.
D. Recognize that it is essential for the partner to be worried within the affected person's care
and inspire participation. - ANS-ANS: C
The fine motion via the nurse can be to involve all events in developing an optimum plan of
care. Because own family individuals who could be helping with the affected person's ongoing
care need to believe their enter is crucial, telling the spouse that the patient can perform sports
independently isn't always the high-quality choice. Reminding the affected person about the
importance of independence won't change the behaviors of the partner. Supporting the sports of
the spouse will lead to ongoing dependency by way of the patient.
, DIF: Cognitive Level: Apply (utility)
A production worker arrives at an urgent care center with a deep puncture wound from a rusty
nail. The patient reports having had a tetanus booster 6 years in the past. The nurse will
anticipate
a. IV infusion of tetanus immune globulin (TIG).
B. Management of the tetanus-diphtheria (Td) booster.
C. Intradermal injection of an immune globulin test dose.
D. Initiation of the tetanus-diphtheria immunization collection. - ANS-ANS: B
If the affected person has now not been immunized inside the beyond five years, management
of the Td booster is indicated because the wound is deep. Immune globulin administration is
given via the IM direction if the affected person has no preceding immunization. Administration
of a sequence of immunization is not indicated. TIG is not indicated for this patient, and a take a
look at dose isn't wanted for immune globulin.
DIF: Cognitive Level: Apply (software)
A patient admitted with dermal ulcers who has a records of a T3 spinal wire injury tells the
nurse, "I have a pounding headache and I experience sick to my belly." Which motion ought to
the nurse take first?
A. Check for a fecal impaction. C. Assess the blood pressure (BP).
B. Give the prescribed antiemetic. D. Notify the fitness care provider. - ANS-ANS: C
The BP must be assessed immediately in a affected person with an injury on the T6 degree or
higher who complains of a headache to determine if autonomic hyperreflexia is going on.
Notification of the patient's health care company is suitable after the BP is acquired.
Administration of an antiemetic is indicated if autonomic hyperreflexia is dominated out because
the cause of the nausea. After checking the BP, the nurse can also assess for a fecal impaction
using lidocaine jelly to prevent similarly multiplied BP.
DIF: Cognitive Level: Analyze (analysis)
A patient has an incomplete left spinal cord lesion at the level of T7, resulting in Brown-Séquard
syndrome. Which nursing motion should be included inside the plan of care?
A. Assessment of the patient for right arm weakness
b. Assessment of the affected person for expanded right leg pain
c. Positioning the patient's left leg while turning the affected person
d. Teaching the affected person to take a look at the right leg to verify its function - ANS-ANS: C
The affected person with Brown-Séquard syndrome has loss of motor feature on the ipsilateral
facet and will require the nurse to transport the left leg. Pain sensation will be misplaced inside
the affected person's proper leg. Arm weakness will now not be a trouble for a affected person
with a T7 damage. The affected person will keep function experience for the proper leg.
DIF: Cognitive Level: Apply (software)
A patient hospitalized with a new analysis of Guillain-Barré syndrome has numbness and weak
spot of each feet. The nurse will anticipate coaching the affected person about
a. Infusion of immunoglobulin
