NUR 216 E1

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TomWruble
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NUR 216 E1
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2013-11-17 15:17:04
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Chapters 45 47
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Care of pts w/ spinal cord problems (45) and critically ill pts w/ neorologic probs (47)
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  1. Acute back pain is usually self-limiting. If the pain continues for AAA or if repeated episodes of pain occur, the patient has chronic back pain.
    A) 3 months
  2. The lumbosacral (lower back) and cervical (neck) vertebrae are most commonly affected because these are the areas where the vertebral column is AAA.
    A) the most flexible
  3. Factors Contributing to Low Back Pain
    • Changes in support structures
    • Spinal stenosis (narrowing)
    • Hypertrophy (increase in the volume of an organ or tissue due to the enlargement of its component cells*) of the intraspinal ligaments
    • Osteoarthritis (When bone surfaces become less well protected by cartilage, bone may be exposed and damaged)
    • Changes in vertebral support and malalignment
    • Scoliosis
    • Lordosis (Excessive lordotic curvature is also called hyperlordosis, hollow back, saddle back, and swayback.)
    • Vascular changes
    • Diminished blood supply to the spinal cord or cauda equina ( bundle of spinal nerves and spinal nerve roots, consisting of the second through fifth lumbar nerve pairs, the first through fifth sacral nerve pairs, and the coccygeal nerve,) caused by arteriosclerosis
    • Blood dyscrasias (an unspecified disorder of the blood...presence of abnormal material in the blood...usually applied to diseases affecting blood cells or platelets)
    • Intervertebral disk degeneration

    *hyperplasia - cells remain approximately the same size but increase in number
  4. Nonsurgical management of back pain includes participate in a regular exercise program, especially one that promotes back strengthening, such as AAA and BBB.
    • A) swimming
    • B) walking
  5. An inability to void may indicate damage to the sacral spinal nerves, which control the AAA muscle in the bladder.
    A) detrusor
  6. Correct turning of the patient in bed is especially important. Teach the patient to log roll every AAA hours from side to back and vice versa.
    A) 2
  7. If conservative (non-surgical) treatments do not work for cervical neck pain, a soft collar may be used at night for a period of no longer than AAA days.
    A) 10
  8. If conservative treatment for neck pain is ineffective, surgery such as an AAA is commonly performed.
    A) anterior cervical discectomy and fusion
  9. Cervical neck pain most often results from ...
    a bulging or herniation of the nucleus pulposus (HNP) in an intervertebral disk.
  10. Hyperextension injuries occur most often in vehicle collisions in which the vehicle is struck from behind or during falls when the patient's chin is struck. This stretches or tears the anterior longitudinal ligament, fractures or [subluxates]? the vertebrae.
    incomplete or partial dislocation
  11. axial loading is ...
    vertical compression
  12. Incomplete SCIs are (more/less) common than complete lesions.
    more
  13. Anterior cord syndrome results from damage to the anterior portion of AAA matter of the spinal cord, usually as a result of BBB.
    • A) both gray and white
    • B) decreased blood supply
  14. With anterior cord syndrome AAA are lost below the level of injury, but the sensations of BBB remain intact.
    • A) motor function and pain and temperature sensation
    • B) touch, position, and vibration
  15. With posterior cord lesion AAA are lost below the level of injury, but BBB remain intact.
    • A) touch, position, and vibration sensations
    • B) motor function and pain and temperature sensation
  16. Compared with anterior cord syndrome, posterior cord syndrome is seen (more/less) often.
    less
  17. Brown-Séquard syndrome results from AAA injuries that cause BBB.
    • A) penetrating
    • B) hemisection of the spinal cord or injuries that affect half of the spinal cord
  18. In Brown-Séquard syndrome motor function, proprioception, vibration, and deep touch sensations are lost on the (ipsilateral/contralateral) side relative to the damage.
    ipsilateral
  19. In Brown-Séquard syndrome the sensations of pain, temperature, and light touch are affected (ipsilateral/contralateral) to the injury.
    contralateral
  20. As a result of spinal nerve tract crossing, these deficits are manifest contralateral to the injured hemisphere?
    pain, temperature, and light touch
  21. Lesions of the central portion of the spinal cord produce a central cord syndrome resulting in ...
    loss of motor function that is more severe in the upper extremities than in the lower extremities with varying degrees and patterns of sensation remaining intact.
  22. Damage to the cauda equina or conus medullaris produces a variable pattern of motor or sensory loss because ...
    the peripheral nerves have the potential for recovery and regrowth.
  23. Neurogenic bowel and bladder usually results from damage to the ...
    cauda equina or conus medullaris.
  24. SCI etiology
    • 50% result from motor vehicle crashes
    • falls
    • acts of violence and sports/recreation accidents
    • diseases such as tumors.
  25. Assessing AAA is the priority for any trauma patient.
    A) the ABCs (airway, breathing, circulation)
  26. Spinal shock, also called spinal shock syndrome, occurs immediately as a concussion response to the injury. The patient has AAA and BBB below the level of the lesion. It often lasts CCC.
    • A) flaccid paralysis
    • B) loss of reflex activity
    • C) less than 48 hours but may continue for several weeks - usually resolves within 24 hours
  27. To assess C4-5 ...
    apply downward pressure while the patient shrugs his or her shoulders upward.
  28. To assess C5-6 ...
    apply resistance while the patient pulls up his or her arms.
  29. To assess C7 ...
    apply resistance while the patient straightens his or her flexed arms.
  30. To assess C8 ...
    make sure the patient is able to grasp an object and form a fist.
  31. To assess L2-4 ...
    apply resistance while the patient lifts his or her legs from the bed.
  32. To assess L5 ...
    apply resistance while the patient dorsiflexes his or her feet.
  33. To assess S1 ...
    apply resistance while the patient plantar flexes his or her feet.
  34. Cardiovascular dysfunction is usually the result of disruption of the autonomic nervous system especially if the injury is above the AAA vertebra. Systolic blood pressure below BBB mm Hg requires treatment because lack of perfusion to the spinal cord could worsen the patient's condition
    • A) 6th thoracic
    • B) 90
  35. Respiratory assessment for SCI includes ...
    vital capacity and minute volume - done by a respiratory therapist...
  36. In AAA injuries the reflex arcs connecting the bowel to the spinal cord remain intact. Reflex activity continues but is uncontrolled. The anal sphincters retain their tone and remain closed. When the rectum fills an uncontrolled reflex may cause the sphincters to relax and the rectum to contract. This pushes the stool out of the anus. This type of function is called upper motor neurone or BBB.
    • A) cervical and thoracic
    • B) reflex bowel
  37. What is paraparesis of the upper limbs?
    It would be "weakness" as opposed to "paralysis", but in a SCI lower limbs would be affected along with upper limbs making the condition quadriparesis.
  38. Oftentimes, pts. who can flex their elbow but not extend their arm have injuries at their ...
    5th or 6th cervical vertebra
  39. Lower motor neuron (LMN) lesions (usually lower thoracic or lumbosacral injuries) can result in ...
    muscle wasting results from the long-term flaccid paralysis.
  40. Incomplete lesions or upper motor neuron (UMN) lesions (usually cervical and upper thoracic injuries) cause
    muscle spasticity, which can lead to contractures after spinal shock has resolved.
  41. A client had a cervical spinal fusion and halo fixation device with jacket placed 2 days ago. He reports to you that he has a severe headache, and he has perspiration on his forehead. His face is flushed, and he reports nausea. What is the nurse’s first action in caring for this client?

    A. Provide an emesis basin in case he vomits.
    B. Check his bladder for distention
    C. Raise the head of his bed now.
    D. Report his symptoms to the physician.
    C. Raise the head of his bed now.

    These are symptoms of autonomic dysreflexia, which causes severe hypertension that, if not immediately treated, will result in a stroke. Elevating the head of the bed will immediately lower the blood pressure. The nurse should then check the vital signs and check for any noxious stimuli that precipitated the event such as a distended bladder or constipation. The health care provider should be notified. Treat the cause of the stimulation. Monitor the blood pressure every 10 to 15 minutes. Administer medication (nitrates or hydralazine) as prescribed.

    Symptoms include:
    intense headaches
    profuse sweating
    facial erythema
    goose bumps
    nasal stuffiness
    a "feeling of doom" or apprehension
    blurred vision.

    An elevation of 40 mm. Hg. over baseline systolic should be suspicious for dysreflexia.
    (this multiple choice question has been scrambled)
  42. The patient is a 23-year-old man who sustained a C7 fracture during a skiing accident. He is being transferred from the medical-surgical unit to the inpatient rehabilitation unit. He has family in the area and they have been supportive throughout his hospital stay. His mother, in particular, has spent many hours at the bedside and expresses a willingness to take him home and continue his care once his hospital and rehab treatment are completed. The patient has lost approximately 18 lbs. during the hospital stay and demonstrates a weak non-productive cough. He had been actively participating with physical therapy and occupational therapy, but he is currently discouraged and withdrawn.

    Why is this patient at risk for pneumonia and what nursing interventions could be used to help prevent this complication?
    The patient is at risk for pneumonia because of impaired mobility and debilitated state. He has also become less willing to actively participate in the treatment plan. Encourage the use of an incentive spirometer; perform oral or nasal suctioning as needed; encourage the patient to cough, or use cough assist; assess lungs at least every 8 hours; turn every 2 hours.
  43. The patient is a 23-year-old man who sustained a C7 fracture during a skiing accident. He is being transferred from the medical-surgical unit to the inpatient rehabilitation unit. He has family in the area and they have been supportive throughout his hospital stay. His mother, in particular, has spent many hours at the bedside and expresses a willingness to take him home and continue his care once his hospital and rehab treatment are completed. The patient has lost approximately 18 lbs. during the hospital stay and demonstrates a weak non-productive cough. He had been actively participating with physical therapy and occupational therapy, but he is currently discouraged and withdrawn.

    What are the major complications of prolonged immobility?
    Postural hypotension, skin breakdown, DVTs, osteoporosis, constipation, pulmonary emboli
  44. The patient is a 23-year-old man who sustained a C7 fracture during a skiing accident. He is being transferred from the medical-surgical unit to the inpatient rehabilitation unit. He has family in the area and they have been supportive throughout his hospital stay. His mother, in particular, has spent many hours at the bedside and expresses a willingness to take him home and continue his care once his hospital and rehab treatment are completed. The patient has lost approximately 18 lbs. during the hospital stay and demonstrates a weak non-productive cough. He had been actively participating with physical therapy and occupational therapy, but he is currently discouraged and withdrawn.

    What are the expected outcomes of a bladder retraining program?
    Have a predictable pattern of voiding, void more than 150 mL each time, empty the bladder completely, manage clothing independently, have no urinary incontinence, have no urinary infection
  45. The patient is a 23-year-old man who sustained a C7 fracture during a skiing accident. He is being transferred from the medical-surgical unit to the inpatient rehabilitation unit. He has family in the area and they have been supportive throughout his hospital stay. His mother, in particular, has spent many hours at the bedside and expresses a willingness to take him home and continue his care once his hospital and rehab treatment are completed. The patient has lost approximately 18 lbs. during the hospital stay and demonstrates a weak non-productive cough. He had been actively participating with physical therapy and occupational therapy, but he is currently discouraged and withdrawn.

    What are the essential elements of a bowel retraining program?
    Stool softeners, increased fluid intake (unless medically contraindicated), high-fiber diet, and a consistent time for elimination
  46. neurogenic shock?
    Neurogenic shock is a type of hypovolemic shock causing:

    • • Severe bradycardia
    • • Warm, dry skin
    • • Severe hypotension

    Notify the physician immediately if these symptoms occur, because this problem is an emergency! Neurogenic shock is treated symptomatically by restoring fluids to the circulating blood volume.

    a distributive [defined by hypotension and generalized tissular hypoxia. This form of relative hypovolemia is the result of blood vessel dilation.] type of shock resulting in hypotension, occasionally with bradycardia, that is attributed to the disruption of the autonomic pathways within the spinal cord.
  47. Tetraplegia or quadriplegia and quadriparesis or weakness involve all four extremities, as seen with ...
    cervical cord and upper thoracic injury.
  48. Paraplegia and paraparesis involve only the lower extremities, as seen in ...
    lower thoracic and lumbosacral injuries or lesions.
  49. Cardiovascular dysfunction from disruption of the AAA, results in BBB, CCC and DDD.
    • A) autonomic nervous system
    • B) bradycardia
    • C) hypotension
    • D) hypothermia
  50. With SCI, assess the abdomen for indications of ...
    hemorrhage, distention, or paralytic ileus
  51. Primary spinal cord tumors arise from the ...
    epidural vessels, spinal meninges, or glial cells of the cord
  52. Tumors that involve the bones of the vertebral column usually occur ...
    as a result of metastasis from other areas of the body
  53. AAA provides more detail of the pathologic condition of the spinal cord than either BBB.
    • A) Magnetic resonance imaging scan
    • B) a computed tomography scan or myelography
  54. AAA may help make a differential diagnosis to BBB.
    • A) Electromyography, a technique for evaluating physiologic properties of muscles,
    • B) rule out multiple sclerosis or amyotrophic lateral sclerosis
  55. AAA is a chronic autoimmune disease that affects BBB and is a leading cause of neurologic disability in young adults.
    • A) Multiple sclerosis
    • B) the myelin sheath and conduction pathway of the central nervous system
  56. Multiple sclerosis is a ...
    chronic autoimmune disease that affects the myelin sheath and conduction pathway of the central nervous system and is a leading cause of neurologic disability in young adults.

    periods of remission and exacerbation of an inflammatory response that results in demyelinization

    having a first-degree relative such as a parent or sibling with MS increases a person’s risk of developing the disease.
  57. Amyotrophic lateral sclerosis, also known as Lou Gehrig’s disease, is an ...
    adult onset upper and lower motor neuron disease characterized by progressive weakness, muscle wasting and spasticity eventually leading to paralysis.
  58. Situation: Your patient is a 23-year-old man with a spinal cord injury from a diving incident. He is in a halo fixator. An indwelling urinary catheter is in place, and he is on a bowel retraining program. As you enter his room, he states he has a throbbing headache. His face is flushed, and he is hypertensive. The physician prescribes hydralazine (Apresoline) to be given. Why are you giving this medication?

    A. To resolve the patient’s headache
    B. To relieve the patient’s anxiety
    C. To treat autonomic dysreflexia
    D. To promote diuresis
    C. To treat autonomic dysreflexia

    This is a neurologic emergency and must be treated promptly
    (this multiple choice question has been scrambled)
  59. Your patient is a 34-year-old woman with multiple sclerosis. She has been doing well, but during the most recent cold experienced in your area, she has had more loss of function than ever before. She is still able to walk and carry out all activities of daily living; however, they take quite a long time to accomplish. She has been taking glatiramer acetate (Copaxone). She asks how this medication works. What is your best response?

    A. This medication decreases myelin loss through antiviral activities.
    B. This medication is an immunomodulator that modifies the course of the disease.
    C. This medication is a monoclonal antibody that binds to WBCs, preventing further damage to the myelin.
    D. This medication is a synthetic protein that simulates myelin-based protein.
    D. This medication is a synthetic protein that simulates myelin-based protein.
    (this multiple choice question has been scrambled)
  60. Your patient is a 34-year-old woman with multiple sclerosis. She has been doing well, but during the most recent cold experienced in your area, she has had more loss of function than ever before. She is still able to walk and carry out all activities of daily living; however, they take quite a long time to accomplish. She has been taking glatiramer acetate (Copaxone). Her physician adds mitoxantrone (Novantrone) to her medication regimen. She asks you what this medication will do.

    A. This medication will produce myelin to help improve function.
    B. This medication will increase cortisol in the system, which will suppress myelin destruction.
    C. This medication will reduce neurologic disability and frequency of relapses.
    D. This medication will decrease incidence of muscle spasticity.
    C. This medication will reduce neurologic disability and frequency of relapses.

    Mitoxantrone (Novantrone), an antineoplastic agent, has been shown to be effective in reducing neurologic disability and the frequency of clinical relapses in patients with secondary-progressive, progressive-relapsing, or worsening relapsing-remitting MS.
    (this multiple choice question has been scrambled)
  61. Your patient is a 36-year-old construction worker with severe chronic back pain. He has had to change jobs because of his inability to work in construction. He is in the office to determine if he is able to have an intrathecal infusion through an implanted pump. He wants to know how ziconotide (Prialt) will work in this device. What is your best response to his question?

    A. This medication will block Na channels on the nerves, thus blocking the sensation of pain.
    B. Ziconotide (Prialt) is a new steroid that will decrease swelling in the back, thus decreasing back pain.
    C. This medication will block calcium channels on the nerves that transmit pain to the brain.
    D. This medication will increase norepinephrine receptors in the CNS, thus blocking transmission of pain to the brain.
    C. This medication will block calcium channels on the nerves that transmit pain to the brain.

    Ziconotide (Prialt) is used for severe chronic pain and is given by intrathecal (spinal) infusion with a surgically implanted pump. It is the first available drug in a new class called N-type calcium channel blockers. This medication seems to selectively block calcium channels on those nerves that usually transmit pain signals to the brain.
    (this multiple choice question has been scrambled)
  62. Your patient is a 36-year-old construction worker with severe chronic back pain. He has had to change jobs because of his inability to work in construction. He is in the office to determine if he is able to have an intrathecal infusion through an implanted pump. It was found that he is not a candidate for this device. He is also experiencing muscle spasticity in the muscles of his legs. Which medications may he take for this problem? Select all that apply.

    A. Dantrolene sodium (Dantrium)
    B. Baclofen (Lioresal)
    C. Carbamazepine (Tegretol)
    D. Amantadine hydrochloride (Symmetrel)
    A and B

    Baclofen (Lioresal), diazepam (Valium), or dantrolene sodium (Dantrium) to lessen muscle spasticity.
  63. An RN from the general surgery unit has been assigned to the neurosurgical unit for the day. Which patient should be assigned to the float RN?

    A) A patient who had a T1 spinal cord injury yesterday who needs assessment of sensation and motor ability every 4 hours
    B) A patient with chronic back pain who is being assessed for the effectiveness of different pain medication and exercise regimens
    C) A patient who arrived 4 hours ago after a laminectomy with a spinal fusion
    D) A patient who has been placed in a halo fixation device after a spinal cord injury
    B) A patient with chronic back pain who is being assessed for the effectiveness of different pain medication and exercise regimens

    A general surgical RN will be skilled in assessing the effectiveness of pain treatments and medication. All of the other patients require specialized neurologic assessments and care that should be done by nurses who are experienced in caring for neurosurgical patients.
    (this multiple choice question has been scrambled)
  64. You are caring for a patient postoperatively after an anterior cervical discectomy and fusion. Which assessment finding is of most concern?

    A) Serosanguinous fluid oozes onto the neck dressing.
    B) The patient has hoarseness and some difficulty swallowing secretions.
    C) The patient's neck pain is at a level 7 (0-to-10 scale).
    D) The patient has numbness and tingling bilaterally down the arms.
    B) The patient has hoarseness and some difficulty swallowing secretions.

    Hoarseness and difficulty swallowing may indicate swelling in the neck and the potential for compromise of the patient's airway. The other findings are expected after this surgery.
    (this multiple choice question has been scrambled)
  65. You are caring for a patient in the emergency department whose spinal cord was injured at the level of C7 1 hour ago. Which assessment finding requires the most rapid action?

    A) The patient demonstrates a flaccid paralysis below the level of the injury.
    B) Electrocardiographic monitoring shows a sinus bradycardia at a rate of 50.
    C) After two fluid boluses, the patient’s systolic blood pressure remains 80.
    D) The patient’s chest moves very little with each respiration, and the SPO2 is 88%.
    D) The patient’s chest moves very little with each respiration, and the SPO2 is 88%.

    All of these interventions for autonomic dysreflexia are appropriate, but getting the patient to sit upright is the easiest thing to do and has the most immediate chance of lowering the blood pressure to the brain.
    (this multiple choice question has been scrambled)
  66. The client has received preoperative teaching from the nurse for a microdiskectomy. Which statement by the client indicates understanding of the nurse's instruction?

    A. ''I can go home the day of the procedure.''
    B. ''I'll have a drain in place after the procedure.''
    C. ''I can go home in 48 hours after the procedure.''
    D. ''I'll need to wear special stockings after the procedure.''
    A. ''I can go home the day of the procedure.''

    All others are assoc. w/ traditional open laminectomy
    (this multiple choice question has been scrambled)
  67. The client with a spinal cord injury exhibits signs of severe hypertension, bradycardia, severe headache, nasal stuffiness, and flushing. What is the priority nursing intervention for this client?

    A. Unkinking the Foley catheter tubing
    B. Notifying the health care provider on call
    C. Assessing blood pressure every 10 to 15 minutes
    D. Placing the client in a sitting position
    D. Placing the client in a sitting position

    Sitting the client up reduces blood pressure and sometimes relieves the triggering stimulus.

    Unkinking the Foley catheter is the second priority. Bladder distention can be the stimulus causing autonomic dysreflexia.

    Calling the health care provider for notification of the event and further orders would be the third priority.
    (this multiple choice question has been scrambled)
  68. The client with a spinal cord tumor and poor prognosis has lost bladder control. The client asks the nurse whether the suggested surgery would be ''worth it.'' What is the nurse's best response?

    A. ''Let me call the surgeon so you can ask the rest of your questions.''
    B. ''It should help return bladder control.''
    C. ''What do you think?''
    D. ''What does your family think?''
    B. ''It should help return bladder control.''

    Surgical decompression may be performed to maintain bladder, bowel, or motor function and to preserve quality of life, even with a poor prognosis.

    The client must make the decision for surgery, but the nurse should provide additional information to the client, especially if the client asks.
    (this multiple choice question has been scrambled)
  69. Neurogenic shock (which is characterized by ???) may occur within 24 hours after injury and most commonly in clients with injuries above T6.
    hypotension, bradycardia, and warm, dry skin
  70. The nurse is providing instructions to a client with a spinal injury about caring for the halo device. The nurse plans to include which instructions?

    A. Begin driving 1 week after discharge.
    B. Swimming is recommended to keep active.
    C. Avoid using a pillow under the head while sleeping.
    D. Keep straws available for drinking fluids.
    D. Keep straws available for drinking fluids.
    (this multiple choice question has been scrambled)
  71. A client with serve muscle spasticity has been prescribed tizanidine (Zanaflex, Sirdalud). The nurse plans to instruct the client about which adverse effect of tizanidine?

    A. Tachycardia.
    B. Hypertension.
    C. Drowsiness.
    D. Hirsutism
    C. Drowsiness.

    Also, alopecia, hypotension and bradycardia
    (this multiple choice question has been scrambled)
  72. The nurse is caring for a client with a spinal cord injury resulting from a diving accident, who has a halo fixator and an indwelling catheter in place. The nurse notes that the blood pressure is elevated and that the client is reporting a severe headache. The nurse anticipates that the health care provider will request which medication?

    A. Ziconotide (Prialt)
    B. Hydralazine (Apresoline)
    C. Methylprednisolone (Solu-Medrol)
    D. Dopamine hydrochloride (Inotropin)
    B. Hydralazine (Apresoline)

    Dopamine hydrochloride (Inotropin) is an inotropic agent used to treat severe hypotension.

    Methylprednisolone (Solu-Medrol) is a glucocorticoid and is not indicated because it may further increase blood pressure.

    Ziconotide (Prialt) is an N-type calcium channel blocker that is used to treat severe chronic back pain and failed back surgery syndrome (FBSS) and is also used for clients with cancer, AIDS, and unremitting pain from other nervous system disorders.
    (this multiple choice question has been scrambled)
  73. Tensilon is a drug used for AAA by BBB. If antidote is CCC in case of DDD.
    • A) pharmacologic test for MG
    • B) inhibiting ACh breakdown for 4-5 minutes wherein most MG patients show marked muscle tome improvement.
    • C) atropine sulfate
    • D) ventricular fibrillation and cardiac arrest
  74. The nurse is providing medication instructions to a client diagnosed with amyotrophic lateral sclerosis (ALS) who has been prescribed riluzole (Rilutek). Which statement indicates to the nurse that the client understands the instructions?

    A. "I will need frequent checks of my liver enzymes."
    B. "I plan to take riluzole once daily."
    C. "I will call the physician if my pulse goes below 50."
    D. "Riluzole should be taken with food."
    A. "I will need frequent checks of my liver enzymes."

    Riluzole (Rilutek) should be taken without food and when the stomach is empty.

    Riluzole (Rilutek) is taken twice a day.

    Riluzole (Rilutek) may cause tachycardia, not bradycardia.
    (this multiple choice question has been scrambled)
  75. A 74-year-old man is admitted to the emergency department (ED) after a fall from a ladder. A nursing history reveals that he was helping a friend fix his roof while drinking several beers on a very hot day. On assessment you find that he is alert and oriented but reports that his head is sore. No swelling, bruising, or bleeding is evident. His vital signs are within normal limits except for his blood pressure which is 184/106. He has a history of hypertension and diabetes mellitus which are controlled by drug therapy and diet. His wife tells you that he doesn’t always take his medication and that he drinks “a lot.”

    1. What other assessment data do you need at this time?
    Because the patient is alert and oriented:

    • ● Ask how many beers he drank and when.
    • ● Ask when the last time he ate anything was.
    • ● Assess capillary the blood glucose level.
    • ● Assess neurologic status, including cognitive functioning and any motor or sensory deficits.
    • ● Assess for abnormalities in the cranial nerves, such as inability to swallow or chew, that would place the patient at risk for aspiration.
  76. A 74-year-old man is admitted to the emergency department (ED) after a fall from a ladder. A nursing history reveals that he was helping a friend fix his roof while drinking several beers on a very hot day. On assessment you find that he is alert and oriented but reports that his head is sore. No swelling, bruising, or bleeding is evident. His vital signs are within normal limits except for his blood pressure which is 184/106. He has a history of hypertension and diabetes mellitus which are controlled by drug therapy and diet. His wife tells you that he doesn’t always take his medication and that he drinks “a lot.”

    2. For what health problems should you carefully monitor and why?
    • ● Monitor for signs of increased intracranial pressure (ICP) because this might manifest gradually.
    • ● Monitor vital signs and blood glucose levels. The patient may be hypoglycemic or hyperglycemic depending on how well his diabetes was controlled and how much alcohol he consumed.
    • ● Watch for changes in levels of consciousness and confusion. These are early signs of ICP along with nausea, vomiting, increased headache, weakness, dizziness, behavioral changes, and loss of memory. After a mild head injury, these symptoms may last from a few days to weeks. It is important to note any significant changes and report to the health care provider immediately.
  77. A 74-year-old man is admitted to the emergency department (ED) after a fall from a ladder. A nursing history reveals that he was helping a friend fix his roof while drinking several beers on a very hot day. On assessment you find that he is alert and oriented but reports that his head is sore. No swelling, bruising, or bleeding is evident. His vital signs are within normal limits except for his blood pressure which is 184/106. He has a history of hypertension and diabetes mellitus which are controlled by drug therapy and diet. His wife tells you that he doesn’t always take his medication and that he drinks “a lot.”

    3. What risk factors does he have for these problems?
    The patient is 74, a diabetic, and hypertensive, as well as noncompliant with medication.
  78. A 74-year-old man is admitted to the emergency department (ED) after a fall from a ladder. A nursing history reveals that he was helping a friend fix his roof while drinking several beers on a very hot day. On assessment you find that he is alert and oriented but reports that his head is sore. No swelling, bruising, or bleeding is evident. His vital signs are within normal limits except for his blood pressure which is 184/106. He has a history of hypertension and diabetes mellitus which are controlled by drug therapy and diet. His wife tells you that he doesn’t always take his medication and that he drinks “a lot.”

    4. While waiting for the CT scan, the patient begins to vomit profusely. What action should you take at this time and why?
    Projectile and profuse vomiting is a sign of increased intracranial pressure. The nurse should elevate the head of the bed and contact the physician immediately. Assess vital signs and oxygenation. The patient should be returned to the emergency department for further evaluation and interventions.
  79. An older client is admitted to the critical care unit after a left carotid endarterectomy this morning. Which nursing assessment finding is the most important to report to the surgeon?

    A. Pain rated at 5 on a 1-10 scale
    B. Increased drowsiness
    C. Nausea when moving in bed
    D. Blood pressure of 148/86 mm Hg
    B. Increased drowsiness

    Increased drowsiness could be caused by hyperperfusion due to the increase of blood flow and could cause a stroke. This should be reported to the health care provider. Instruct the client on what to report to the physician after discharge, especially changes in brain function.
    (this multiple choice question has been scrambled)
  80. How does rtPA (Retavase) work?
    It degrades the thrombus by breaking down fibrin.
  81. Situation: Your patient is a 59-year-old woman with a history of hypertension and elevated cholesterol. She is a longtime smoker. She presents to the emergency department with sudden onset of slurred speech and weakness. She has regained some speech but continues to have right hemiparesis. Her blood pressure is 176/102. Stroke is diagnosed, and rtPA (Retavase) is prescribed. She is placed on warfarin (Coumadin). She is experiencing increased bleeding. What would you expect to give to this patient? Select all that apply.

    A. Naloxone
    B. Meperidine
    C. Vitamin K
    D. Protamine sulfate
    C. Vitamin K

    Vitamin K reverses the effects of warfarin.
    (this multiple choice question has been scrambled)
  82. Situation: Your patient is a 59-year-old woman with a history of hypertension and elevated cholesterol. She is a longtime smoker. She presents to the emergency department with sudden onset of slurred speech and weakness. She has regained some speech but continues to have right hemiparesis. Her blood pressure is 176/102. Stroke is diagnosed, and rtPA (Retavase) is prescribed. She is placed on warfarin (Coumadin). She is experiencing some bleeding, so the physician changed her medication to heparin. If the patient experiences bleeding from this medication, what would the nurse expect to give? Select all that apply.

    A. Vitamin K
    B. Meperidine
    C. Protamine sulfate
    D. Naloxone
    C. Protamine sulfate

    Protamine sulfate is used to reverse the effects of heparin.
    (this multiple choice question has been scrambled)
  83. Your patient is a 59-year-old woman with a history of hypertension and elevated cholesterol, and she is a longtime smoker. She presents to the emergency department with sudden onset of slurred speech and weakness. She has regained some speech but continues to have right hemiparesis. Her blood pressure is 176/102. Stroke is diagnosed, and rtPA (Retavase) is prescribed. She is placed on warfarin (Coumadin). She is experiencing some bleeding, so the physician changed her medication to heparin. While the patient is on this medication, what lab value should the nurse monitor? Select all that apply.

    A. CBC
    B. PTT
    C. Hgb and Hct
    D. INR
    B. PTT

    Baseline Prothrombin time (PT) and partial thromboplastin time (PTT) values are usually obtained before initiating heparin therapy, 6 to 8 hours after the start of the infusion, and every day while the patient is receiving heparin therapy. The therapeutic goal is to achieve 1.5 to 2 times the patient's normal baseline PT and PTT values.

    PT is used to monitor oral anticoagulant therapy.

    PTT is used to monitor heparin therapy.
    (this multiple choice question has been scrambled)
  84. Your patient is a 59-year-old woman with a history of hypertension and elevated cholesterol, and she is a longtime smoker. She presents to the emergency department with sudden onset of slurred speech and weakness. She has regained some speech but continues to have right hemiparesis. Her blood pressure is 176/102. Stroke is diagnosed, and rtPA (Retavase) is prescribed. What are the contraindications to thrombolytic therapy? Select all that apply.

    A. Smoking history
    B. Head injury within the past 3 months
    C. Increased partial thromboplastin time (PTT)
    D. Pregnancy
    B, C and D
  85. Your patient is a 59-year-old woman with a history of hypertension and elevated cholesterol. She is a longtime smoker. She presents to the emergency department with sudden onset of slurred speech and weakness. She has regained some speech but continues to have right hemiparesis. Her blood pressure is 176/102. Stroke is diagnosed, and rtPA (Retavase) is prescribed. She is placed on warfarin (Coumadin). What signs specifically related to Coumadin should you observe? Select all that apply.

    A. Decreased blood pressure
    B. Irregular heart rate
    C. Bruising
    D. Blood in urine or stool
    C and D

    Anticoagulants such as warfarin may cause bleeding. It is contraindicated in patients who have ulcers, uremia, or hepatic failure.
  86. The charge nurse for the neurosurgical unit is making assignments for a nurse who floated from the pediatric unit. Which patient should be assigned to the float nurse?

    A. A 72-year-old with an acute ischemic stroke who is receiving IV thrombolytic therapy
    B. A 59-year-old who had a carotid endarterectomy and needs neurologic and vital sign monitoring
    C. A 45-year-old with an arteriovenous malformation who is complaining of a headache
    D. A 47-year-old who has possible intracerebral hemorrhage and is awaiting testing for brain activity
    B. A 59-year-old who had a carotid endarterectomy and needs neurologic and vital sign monitoring

    Postoperative complications are uncommon after carotid endarterectomy, so this patient is the most stable. The float nurse would be familiar with vital sign and neurologic checks. The other patients have diagnoses and/or therapies that have a higher risk for complications. They should be cared for by RNs who are experienced in caring for patients with acute neurologic problems.
    (this multiple choice question has been scrambled)
  87. Which assessment finding for a patient with a left-sided ischemic stroke who is receiving recombinant tissue plasminogen activator (rtPA, Retavase ) should be reported immediately to the physician?

    A. The patient has continued right-sided weakness.
    B. There is prolonged bleeding at blood-draw sites.
    C. The blood pressure is 170/102.
    D. The patient denies having a stroke.
    C. The blood pressure is 170/102.

    The elevated blood pressure places the patient who is receiving fibrinolytic drugs at risk for intracerebral hemorrhage. The nurse should notify the physician immediately and expect prescriptions for antihypertensive therapy. The other findings are common or expected in patients with left-sided stroke or who are receiving fibrinolytic therapy.
    (this multiple choice question has been scrambled)
  88. Stroke symptom:
    aphasia, agraphia, alexia

    side affected...
    left
  89. Stroke symptom:
    sense of humor

    side affected...
    right
  90. Stroke symptom:
    sense of humor

    side affected...
    right
  91. Stroke symptom:
    time, place, person, faces

    side affected...
    right
  92. Stroke symptom:
    words, letters, reading

    side affected...
    left
  93. Stroke symptom:
    spacial, depth perception

    side affected...
    right
  94. Stroke symptom:
    slow, anxiety, depression, guilt, anger, intellect

    side affected...
    left
  95. Stroke symptom:
    impulsive, euphoric, smiling, poor judgment

    side affected...
    right
  96. Stroke symptom:
    tonal variations

    side affected...
    right
  97. The client in the emergency department (ED) has slurred speech, confusion, and visual problems, and has been having intermittent episodes of worsening symptoms. The symptoms occur during the day with a gradual onset. The client also has a history of hypertension and atherosclerosis. What does the nurse suspect that the client is probably experiencing?

    A. Hemorrhagic stroke
    B. Transient ischemic attack
    C. Embolic stroke
    D. Thrombotic stroke
    D. Thrombotic stroke

    worsening symptoms -> thrombolytic. Though they are "intermittent episodes of slurred speech, confusion, and visual problems", the "worsening" indicates stroke.
    (this multiple choice question has been scrambled)
  98. The "Mini-Mental State Examination (MMSE; mini-mental status exam)" is used ...
    primarily used to differentiate among dementia, psychosis, and affective disorders.
  99. Protamine sulfate is used to
    reverse the effects of heparin in case of adverse effects.
  100. Vitamin K is used to
    reverse the effects of warfarin.
  101. Physostigmine is ...
    an acetylcholinesterase inhibitor used to treat myasthenia gravis.
  102. The client has had a traumatic brain injury and is comatose. Which technique does the nurse use to prevent increasing intracranial pressure?

    A. Suctioning the client frequently
    B. Maintain PCO2 levels at 35 mm Hg
    C. Placing the client in the Trendelenburg position
    D. Assessing for Turner's sign
    B. Maintain PCO2 levels at 35 mm Hg

    Hemodynamic monitoring is usually instituted for a comatose client with traumatic brain injury. Keeping the PCO2 levels at 35 mm Hg prevents vasodilation which could increase ICP. CO2 is a powerful vasodilator.
    (this multiple choice question has been scrambled)
  103. The client with a traumatic brain injury from a motor vehicle accident is monitored for signs of increased intracranial pressure. Which sign does the nurse monitor for?

    A. Changes in breathing pattern
    B. Dizziness
    C. Increasing level of consciousness
    D. Reactive pupils
    A. Changes in breathing pattern

    Dizziness is indicative of brain injury.
    (this multiple choice question has been scrambled)
  104. Decorticate positioning indicates damage to AAA. The client usually is rigid with flexion of arms, clenched fists, and extended rigid legs.
    A) the pathway between the brain and spinal cord
  105. The nurse is monitoring the postoperative craniotomy client with intracranial pressure. Which pharmacologic agent does the nurse expect to be ordered to maintain the ICP within a specified range?

    A. Hydrochlorothiazide (HydroDIURIL)
    B. Phenytoin (Dilantin)
    C. Dexamethasone (Decadron)
    D. Mannitol (Osmitrol)
    D. Mannitol (Osmitrol)

    Mannitol is an osmotic diuretic used specifically to treat cerebral edema.

    Hydrochlorothiazide is only a mild diuretic. A loop diuretic such as furosemide (Lasix) is commonly used along with Mannitol to reduce ICP.

    Dilantin is used to treat seizure activity caused by increased ICP.
    (this multiple choice question has been scrambled)
  106. Epistaxis is
    a nosebleed
  107. A client with a confirmed acute ischemic stroke is admitted to the medical unit after evaluation in the emergency department. What is the nurse’s priority action on admission?

    A. Consult with the physical therapist about the client’s rehabilitative care.
    B. Keep the client NPO until the swallowing assessment is complete.
    C. Ask the nursing technician to weigh the client and record it.
    D. Give warfarin and check activated thromboplastin levels.
    B. Keep the client NPO until the swallowing assessment is complete.

    Clients who have experienced a stroke may develop swallowing difficulties and are at risk for choking and aspiration. The client should be maintained on NPO status until a swallowing evaluation is performed by the speech therapist.

    Although previously widely used, anticoagulants such as warfarin are controversial and are not considered current best practice by the American Stroke Association for acute ischemic stroke or for preventing future strokes because of the risk of bleeding.
    (this multiple choice question has been scrambled)
  108. An alert and oriented client is admitted to the emergency department with a moderate head injury. Which assessment finding will the nurse report immediately to the health care provider?

    A. Headache
    B. Slight dizziness
    C. Fatigue
    D. Sudden drowsiness
    D. Sudden drowsiness

    The early detection of subtle changes in a client’s neurologic status enables the health care team to prevent or treat potentially life-threatening complications. A sudden neurologic change such as the presentation of drowsiness requires immediate attention because it is a change in the level of consciousness and may signal a medical emergency.

    A headache is a commonly experienced symptom after a head injury.

    Clients often report dizziness after a head injury, and this symptom usually improves over time.

    Fatigue is different than the onset of drowsiness and is often less sudden in presentation than drowsiness. Fatigue is not considered a neurologic change.
    (this multiple choice question has been scrambled)
  109. AAA may be prescribed to prevent or treat heterotopic ossification (i.e. BBB). Early and continued exercise may decrease the incidence of this complication
    • A) celecoxib (Celebrex)
    • B) bony overgrowth
  110. Atelectasis is defined as the ...
    collapse or closure of the lung resulting in reduced or absent gas exchange
  111. Patients with injuries at or above AAA are especially at risk for respiratory complications and BBB during CCC after injury
    • A) T6
    • B) pulmonary embolus
    • C) the first 5 days
  112. For SCI, encourage consumption of AAA of fluid daily to prevent urinary tract infection
    A) 2000 to 2500 mL
  113. The classic picture of the AAA occurs in most of the cases.
    A) relapsing-remitting type of MS (RRMS)

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