ATI LPN
Test Bank for Medical Surgical Nursing: Concepts for Interprofessional Collaborative Care 10th Edition
Chapter 43 : Care of Patients with Problems of the CNS: The Spinal Cord Questions
Question 1 of 5
A nurse assesses a client with paraplegia from a spinal cord injury and notes reddened areas over the client's hips and sacrum. Which actions should the nurse take? (Select all that apply.)
Correct Answer: B,D
Rationale: Repositioning and using a low-air-loss mattress relieve pressure on reddened areas. Rubbing, barrier creams, ROM exercises, and sitting in a chair do not address pressure relief effectively.
Question 2 of 5
A nurse assesses a client who experienced a spinal cord injury at the T5 level 12 hours ago. Which manifestations should the nurse correlate with neurogenic shock? (Select all that apply.)
Correct Answer: A,B,C,D,E
Rationale: Neurogenic shock from a T5 spinal cord injury can cause bradycardia (low heart rate), hypotension (low blood pressure), cool and clammy skin, decreased urinary output due to reduced perfusion, and flaccid paralysis below the injury level.
Question 3 of 5
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?
Correct Answer: A
Rationale: Exercise can strengthen back muscles, reducing the incidence of low back pain. The other options will not prevent low back pain.
Question 4 of 5
A nurse plans care for a client with lower back pain from a work-related injury. Which intervention should the nurse include in this work plan care?
Correct Answer: C
Rationale: 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.
Question 5 of 5
A nurse assesses a client who is recovering from a diskectomy 6 hours ago. Which assessment finding should the nurse address first?
Correct Answer: C
Rationale: Difficulty breathing could indicate a compromised airway, possibly due to swelling, which is a critical postoperative complication requiring immediate attention. Pain, numbness, and weak pulses are important but not as urgent as airway issues.