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2024 PERIPHERAL NERVE AND SPINAL CORD PROBLEMS NCLEX CHAPTER 61 EXAM WITH CORRECT ANSWERS
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2024 PERIPHERAL NERVE AND SPINAL CORD PROBLEMS NCLEX CHAPTER 61 EXAM WITH CORRECT ANSWERS
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2024 PERIPHERAL NERVE ANDSPINAL CORD PROBLEMS
NCLEX CHAPTER 61 EXAM WITH
CORRECT ANSWERS
A patient is admitted to the emergency department with a spinal cord injury at the level of T2. Which finding is of
most concern to the nurse?
a. SpO2 of 92%
b. Heart rate of 42 bpm
c. Blood pressure of 88/60 mm Hg
d. Loss of motor and sensory function in arms and legs - CORRECT ANSWERS-b. Neurogenic shock associated with cord injuries
above the level of T6 greatly decreases the effect of
the sympathetic nervous system and bradycardia and
hypotension occur. A heart rate of 42 bpm is not adequate
to meet the oxygen needs of the body. While low, the
blood pressure is not at a critical point. The oxygen
saturation is satisfactory and the motor and sensory losses
are expected.
The patient's spinal cord injury is at T4. What is the highest-level goal of rehabilitation that is realistic for this patient
to have?
a. Indoor mobility in manual wheelchair
b. Ambulate with crutches and leg braces
c. Be independent in self-care and wheelchair use
d. Completely independent ambulation with short leg braces and canes - CORRECT ANSWERS-c. With the injury at T4, the highest-level realistic goal for
this patient is to be able to be independent in self-care and
wheelchair use because arm function will not be affected.
Indoor mobility in a manual wheelchair will be achievable
but it is not the highest-level goal. Ambulating with
crutches and leg braces can be achieved only by patients
with injuries in T6-12 area. Independent ambulation with
short leg braces and canes could occur for a patient with an L3-4 injury. (See Table 61-4.)
What is one indication for early surgical therapy of the patient with a spinal cord injury?
a. There is incomplete cord lesion involvement.
b. The ligaments that support the spine are torn.
c. A high cervical injury causes loss of respiratory function.
d. Evidence of continued compression of the cord is apparent. - CORRECT ANSWERS-d. Although surgical treatment of spinal cord injuries often
depends on the preference of the health care provider,
surgery is usually indicated when there is continued
compression of the cord by extrinsic forces or when there
is evidence of cord compression. Other indications may
include progressive neurologic deficit, compound fracture
of the vertebra, bony fragments, and penetrating wounds
of the cord.
Without surgical stabilization, what method of immobilization for the patient with a cervical spinal cord injury
should the nurse expect to be used?
a. Kinetic beds
b. Hard cervical collar
c. Skeletal traction with skull tongs
d. Sternal-occipital-mandibular immobilizer brace - CORRECT ANSWERS-c. The development of better surgical stabilization has
made surgery the more frequent treatment of cervical
injuries. However, when surgery cannot be done,
skeletal traction with the use of Crutchfield, Vinke, or
other types of skull tongs is required to immobilize
the cervical vertebrae, even if a fracture has not
occurred. Hard cervical collars or a sternal-occipitalmandibular
immobilizer brace may be used after cervical
stabilization surgery or for minor injuries or stabilization
during emergency transport of the patient. Sandbags
may also be used temporarily to stabilize the neck
during insertion of tongs or during diagnostic testing
immediately following the injury. Special turning or
kinetic beds may be used to turn and mobilize patients
who are in cervical traction.
Priority Decision: During assessment of a patient with a spinal cord injury, the nurse determines that the patient has
a poor cough with diaphragmatic breathing. Based on this finding, what should be the nurse's first action?
a. Institute frequent turning and repositioning.
b. Use tracheal suctioning to remove secretions. c. Assess lung sounds and respiratory rate and depth.
d. Prepare the patient for endotracheal intubation and mechanical ventilation. - CORRECT ANSWERS-c. Because pneumonia and atelectasis are potential
problems related to ineffective coughing and the loss of
intercostal and abdominal muscle function, the nurse
should assess the patient's breath sounds and respiratory
function to determine whether secretions are being retained
or whether there is progression of respiratory impairment.
Suctioning is not indicated unless lung sounds indicate
retained secretions. Position changes will help to mobilize
secretions. Intubation and mechanical ventilation are used
if the patient becomes exhausted from labored breathing or
if arterial blood gases (ABGs) deteriorate.
Following a T2 spinal cord injury, the patient develops paralytic ileus. While this condition is present, what should
the nurse anticipate that the patient will need?
a. IV fluids
b. Tube feedings
c. Parenteral nutrition
d. Nasogastric suctioning - CORRECT ANSWERS-d. During the first 2 to 3 days
after a spinal cord injury,
paralytic ileus may occur and nasogastric suction must be
used to remove secretions and gas from the GI tract until
peristalsis resumes. IV fluids are used to maintain fluid
balance but do not specifically relate to paralytic ileus.
Tube feedings would be used only for patients who have
difficulty swallowing and not until peristalsis returns.
Parenteral nutrition would be used only if the paralytic
ileus was unusually prolonged.
Which is most important to respond to in a patient presenting with a T3 spinal injury?
A. Blood pressure of 88/60 mm Hg, pulse of 56 beats/minute
B. Deep tendon reflexes of 1+, muscle strength of 1+
C. Pain rated at 9
D. Warm, dry skin - CORRECT ANSWERS-A. Blood pressure of 88/60 mm Hg, pulse of 56 beats/minute
Neurogenic shock is a loss of vasomotor tone caused by injury, and it is characterized by hypotension and bradycardia. The loss of sympathetic nervous system innervations causes peripheral vasodilation, venous pooling, and a decreased cardiac output. The other options can be expected findings and are not as significant. Patients in neurogenic shock have pink and dry skin, instead of cold and clammy, but this sign is not as important as the vital
signs.
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