Chapter 43. Care of Patients with Problems of the CNS, The Spinal Cord

Chapter 43: Care of Patients with Problems of the CNS: The Spinal Cord MULTIPLE CHOICE 1. 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? 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. ANS: A Exercise can strengthen back muscles, reducing the incidence of low back pain. The other options will not prevent low back pain. DIF: Applying/Application REF: 889 KEY: Pain| spinal cord/back injury MSC: Integrated Process: Teaching/Learning NOT: Client Needs Category: Health Promotion and Maintenance 2. A nurseplans care fora clientwith lower back pain from a work-related injury. Which intervention should the nurse include in this clients plan of care? a. Encourage the client to stretch the back by reaching toward thetoes. b. Massage the affected area with ice twice a day. c. Apply a heating pad for 20 minutes at least four times daily. d. Advise the client to avoid warm baths or showers. ANS: C Heat increases blood flow to the affected area and promotes healing of injured nerves. Stretching and ice will not promote healing, and there is no need to avoid warm baths or showers. DIF: Understanding/Comprehension REF: 890 KEY: Spinal cord/back injury| nonpharmacologic pain management MSC: Integrated Process: Nursing Process: Implementation NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation 3. A nurse assesses a client who is recovering from a diskectomy 6 hours ago. Which assessment finding should the nurse address first? a. Sleepy but arouses to voice b. Dry and cracked oral mucosa c. Pain present in lower back d. Bladder palpated above pubis ANS: D A distended bladder may indicate damage to the sacral spinal nerves. The other findings require the nurseto provide care but are not the priority or a complication of the procedure. DIF: Applying/Application REF: 892 KEY: Back surgery| spinal cord/back injury MSC: Integrated Process: Nursing Process: Analysis NOT: Client Needs Category: Physiological Integrity: Reduction of Risk Potential 4. A nurse assesses clients at a community center. Which client is at greatest risk for lower back pain? 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 ANS: C Osteoarthritis causes changes to support structures, increasing the clients risk for low back pain. The other clients are not at high risk. DIF:Remembering/KnowledgeREF:889 KEY: Spinal cord/back injury| pain MSC: Integrated Process: Nursing Process: Assessment NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation 5. A nurse teaches a client who is recovering from a spinal fusion. Which statement should the nurse include in this clients postoperative instructions? 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. ANS: B Clients who undergo spinal fusion are fitted with a brace that they must wear throughout the healing process (usually 3 to 6 months) whenever they are out of bed. The client should not lift anything. The client does not need to remain in bed. Medications for rejection prevention are not necessary for this procedure. DIF: Applying/Application REF: 891 KEY: Back surgery| spinal cord/back injury MSC: Integrated Process: Teaching/Learning NOT: Client Needs Category: Physiological Integrity: Reduction of Risk Potential 6. 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? a. Auscultated stridor b. Weakpedalpulses c. Difficulty swallowing d. Inability to shrug shoulders ANS: A Postoperativeswelling can narrowthetrachea, causeapartialairwayobstruction, andmanifestasstridor. The client may also have trouble swallowing, but maintaining an airway takes priority. Weak pedal pulses and an inability to shrug the shoulders are not complications of this surgery.