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
The nurse is caring for a client experiencing autonomic dysreflexia. Which of the following does the nurse recognize as the source of symptoms?
Correct Answer: D
Rationale: The nurse recognizes that autonomic dysreflexia is an exaggerated sympathetic nervous system response. Symptoms include severe hypertension, slow heart rate, pounding headache, etc. and can lead to seizures, stroke, and death. The autonomic nervous system regulates 'feed and breed' functions. The central and peripheral nervous system is a component of the sympathetic nervous system.
Question 2 of 5
The nurse is caring for a female client who is newly paraplegic. The client and the client's spouse ask the nurse about their reproductive options. Which suggestion by the nurse is most helpful?
Correct Answer: B
Rationale: The nurse's role is to provide facts without inserting personal opinions. The fact is that the woman can conceive and bear children. Suggesting adoption, a surrogate, or sterilization is not appropriate. Providing information is appropriate.
Question 3 of 5
The nurse is caring for a client who requires spine surgery to remove bone fragments and fuse the vertebrae. From which location will bone be taken for the fusion?
Correct Answer: A
Rationale:
To fuse the vertebrae during surgery, the physician uses bone from the iliac crest. The other options are incorrect.
Question 4 of 5
A middle-aged client has scheduled a sick visit to the physician's office, reporting symptoms of lower back pain with exacerbation upon movement. The nurse draws a picture of the components of the spinal cord and surrounding structures and shows potential causes of the pain. Which area of the drawing would the nurse emphasize?
Correct Answer: B
Rationale: Pressure on the spinal nerve roots result from trauma, herniated disks, and tumors. The nurse would emphasize the nucleus pulposus as a common area of problem. Stress caused by poor body mechanics, age, or disease weakens an area in the vertebra, causing the spongy center of the vertebra, the nucleus pulposus, to swell and herniate. The spinal cord pathway can cause symptoms of numbness and tingling. The bony vertebrae can present symptoms when fractures and bony fragments occur. Associated musculature pulling can place the vertebrae out of alignment causing symptoms.
Question 5 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.