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 immediately after a spinal cord injury. Which assessment finding is essential when caring for a client in spinal shock with injury in the lower thoracic region?
Correct Answer: C
Rationale: Spinal shock is a loss of sympathetic reflex activity below the level of the injury within 30 to 60 minutes after insult. In addition to the paralysis, manifestations include pronounced hypotension, bradycardia, and warm, dry skin. Numbness and tingling and pain are not as high of a concern at this time due to the cord injury. Because the level of impairment is below the first thoracic vertebrae, respiratory failure is not a concern.
Question 2 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 3 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 4 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 5 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.