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 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 2 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 3 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.
Question 4 of 5
An emergency room nurse initiates care for a client with a cervical spinal cord injury who arrives via emergency medical services. Which action should the nurse take first?
Correct Answer: D
Rationale: The first priority for a client with a cervical spinal cord injury is to assess respiratory status and airway patency, as these injuries can compromise breathing. Other assessments follow after ensuring airway and breathing are stable.
Question 5 of 5
An emergency department nurse cares for a client who experienced a spinal cord injury 1 hour ago. Which prescribed medication should the nurse prepare to administer?
Correct Answer: B
Rationale: Methylprednisolone is administered within the first 8 hours of a spinal cord injury to reduce inflammation and improve motor and sensory function. The other medications are not indicated for acute spinal cord injury.