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 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 2 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.
Question 3 of 5
A nurse teaches a client who is recovering from a spinal fusion. Which statement should the nurse include in this client's postoperative instructions?
Correct Answer: B
Rationale: Clients who undergo spinal fusion are fitted with a brace that they must wear throughout the healing process to stabilize the spine. The other options are incorrect: lifting restrictions may vary, bed rest for 3 weeks is not typically required, and rejection medications are not needed for spinal fusion.
Question 4 of 5
A nurse assesses a client who is recovering from anterior cervical diskectomy and fusion. Which complication should the nurse address first?
Correct Answer: C
Rationale: Difficulty breathing indicates a potential airway obstruction, possibly due to postoperative swelling, which is a priority. Stridor and difficulty swallowing are also concerns but maintaining an airway takes precedence. Weak pedal pulses and inability to shrug shoulders are less urgent.
Question 5 of 5
A nurse assesses a client with a spinal cord injury at level T5. The client's blood pressure is 184/95 mm Hg, and the client presents with a flushed face and blurred vision. Which action should the nurse take first?
Correct Answer: C
Rationale: The client is manifesting symptoms of autonomic dysreflexia, likely due to bladder distention. Palpating the bladder to check for distention is the first step to identify and address the cause. The other actions are not appropriate as initial responses.