ATI LPN
Timby's Introductory Medical-Surgical Nursing Thirteenth, North American Edition
Chapter 39 : Caring for Clients With Head and Spinal Cord Trauma Questions
Question 1 of 5
A client presents to the emergency department stating numbness and tingling occurring down the left leg into the left foot. When documenting the experience, which medical terminology would the nurse be most correct to report?
Correct Answer: C
Rationale: A client reports numbness and tingling in an area is reporting a paresthesia. The nurse would document the experience as such or place the client's words in parentheses. The nurse would not make a medical diagnosis of sciatic nerve pain or herniation. The symptoms are not consistent with paralysis.
Question 2 of 5
The nurse is caring for a client with a herniation of C4. What item does the nurse anticipate to use if conservative therapy is used?
Correct Answer: A
Rationale: A C4 injury is in the cervical spine region. A herniated cervical disk is treated conservatively (not surgically) by immobilizing the cervical spine with a cervical collar. Dressing supplies are not needed unless there is a wound. A firm mattress is appropriate for a lumbar herniation. Traction equipment is not used on cervical vertebrae.
Question 3 of 5
The nurse is employed in the neurosurgeon's office assisting the physician in teaching. The nurse is instructing a client who is very anxious, stating, 'What will happen if the conservative treatment for the degenerative changes in my spine does not help my lumbar pain?' The nurse is most correct to turn the teaching to which surgical procedure?
Correct Answer: C
Rationale: The nurse is most correct to provide teaching on a spinal fusion aimed to stabilize the vertebrae weakened by degenerative joint changes such as osteoarthritis and by a laminectomy. A discectomy provides pain relief by the removal of a ruptured disk. A laminectomy is the removal of the posterior arch of a vertebra to expose the spinal cord. From this point, the surgeon can remove a herniated disk, tumor, bone fragments, etc. Aggressive traction is not a surgical option.
Question 4 of 5
The nurse suspects that a newly admitted client is in spinal shock. What is a symptom(s) of spinal shock? Select all that apply.
Correct Answer: A,B,E
Rationale: In addition to paralysis, manifestations include pronounced hypotension, bradycardia, and warm, dry skin. If the level of injury is in the cervical or upper thoracic region, respiratory failure can occur. Bowel and bladder distention develop. The client does not perspire below the level of injury, which impairs temperature control. The client manifests with poikilothermia, body temperature of the environment. Symptoms of spinal shock do not include loss of hunger sensation or circulatory failure.
Question 5 of 5
The nurse is caring for a client with paralysis as a result of a spinal cord injury. When planning care related to the musculoskeletal system, which immediate complication(s) should the nurse consider? Select all that apply.
Correct Answer: C,D
Rationale: Spinal shock is an immediate complication of spinal cord injury, and is characterized by immediate loss of all cord functions below the point of injury. When planning care for clients with a spinal cord injury, the nurse should consider immediate complications including respiratory arrest and spinal shock. Calcium depletion, contractures, and autonomic dysreflexia are all long-term complications of spinal cord injury leading to paralysis.