Nervous System | Neurological Disorders NCLEX Quiz 46

1. A client with a cervical spine injury has Gardner-Wells tongs inserted for which of the following reasons?

To hasten wound healing

To immobilize the cervical spine

To prevent autonomic dysreflexia

To hold bony fragments of the skull together

Gardner-Wells. Vinke. and Crutchfield tongs immobilize the spine until surgical stabilization is accomplished.

Explanation

Gardner-Wells. Vinke. and Crutchfield tongs immobilize the spine until surgical stabilization is accomplished.

2. Which of the following clients on the rehab unit is most likely to develop autonomic dysreflexia?

A client with a brain injury

A client with a herniated nucleus pulposus

A client with a high cervical spine injury

A client with a stroke

Autonomic dysreflexia refers to uninhibited sympathetic outflow in clients with spinal cord injuries about the level of T10. The other clients aren’t prone to dysreflexia.

Explanation

Autonomic dysreflexia refers to uninhibited sympathetic outflow in clients with spinal cord injuries about the level of T10. The other clients aren’t prone to dysreflexia.

3. A client is admitted with a spinal cord injury at the level of T12. He has limited movement of his upper extremities. Which of the following medications would be used to control edema of the spinal cord?

Acetazolamide (Diamox)

Furosemide (Lasix)

Methylprednisolone (Solu-Medrol)

Sodium bicarbonate

High doses of Solu-Medrol are used within 24 hours of spinal injury to reduce cord swelling and limit neurological deficit. The other drugs aren’t indicated in this circumstance.

Explanation

High doses of Solu-Medrol are used within 24 hours of spinal injury to reduce cord swelling and limit neurological deficit. The other drugs aren’t indicated in this circumstance.

4. A 23-year-old client has been hit on the head with a baseball bat. The nurse notes clear fluid draining from his ears and nose. Which of the following nursing interventions should be done first?

Position the client flat in bed

Check the fluid for dextrose with a dipstick

Suction the nose to maintain airway patency

Insert nasal and ear packing with sterile gauze

Clear fluid from the nose or ear can be determined to be cerebral spinal fluid or mucous by the presence of dextrose.Option A: Placing the client flat in bed may increase ICP and promote pulmonary aspiration.Option C: The nose wouldn’t be suctioned because of the risk for suctioning brain tissue through the sinuses.Option D: Nothing is inserted into the ears or nose of a client with a skull fracture because of the risk of infection.

Explanation

Clear fluid from the nose or ear can be determined to be cerebral spinal fluid or mucous by the presence of dextrose.Option A: Placing the client flat in bed may increase ICP and promote pulmonary aspiration.Option C: The nose wouldn’t be suctioned because of the risk for suctioning brain tissue through the sinuses.Option D: Nothing is inserted into the ears or nose of a client with a skull fracture because of the risk of infection.

5. A 22-year-old client with quadriplegia is apprehensive and flushed. with a blood pressure of 210/100 and a heart rate of 50 bpm. Which of the following nursing interventions should be done first?

Place the client flat in bed

Assess patency of the indwelling urinary catheter

Give one SL nitroglycerin tablet

Raise the head of the bed immediately to 90 degrees

Anxiety. flushing above the level of the lesion. piloerection. hypertension. and bradycardia are symptoms of autonomic dysreflexia. typically caused by such noxious stimuli such as a full bladder. fecal impaction. or decubitus ulcer.Option A: Putting the client flat will cause the blood pressure to increase even more.Option B: The indwelling urinary catheter should be assessed immediately after the HOB is raised.Option C: Nitroglycerin is given to reduce chest pain and reduce preload; it isn’t used for hypertension or dysreflexia.

Explanation

Anxiety. flushing above the level of the lesion. piloerection. hypertension. and bradycardia are symptoms of autonomic dysreflexia. typically caused by such noxious stimuli such as a full bladder. fecal impaction. or decubitus ulcer.Option A: Putting the client flat will cause the blood pressure to increase even more.Option B: The indwelling urinary catheter should be assessed immediately after the HOB is raised.Option C: Nitroglycerin is given to reduce chest pain and reduce preload; it isn’t used for hypertension or dysreflexia.

6. When discharging a client from the ER after a head trauma. the nurse teaches the guardian to observe for a lucid interval. Which of the following statements best described a lucid interval?

An interval when the client’s speech is garbled

An interval when the client is alert but can’t recall recent events

An interval when the client is oriented but then becomes somnolent

An interval when the client has a “warning” symptom. such as an odor or visual disturbance.

A lucid interval is described as a brief period of unconsciousness followed by alertness; after several hours. the client again loses consciousness.Option A: Garbled speech is known as dysarthria.Option B: An interval in which the client is alert but can’t recall recent events is known as amnesia.Option D: Warning symptoms or auras typically occur before seizures.

Explanation

A lucid interval is described as a brief period of unconsciousness followed by alertness; after several hours. the client again loses consciousness.Option A: Garbled speech is known as dysarthria.Option B: An interval in which the client is alert but can’t recall recent events is known as amnesia.Option D: Warning symptoms or auras typically occur before seizures.

7. Which of the following interventions describes an appropriate bladder program for a client in rehabilitation for spinal cord injury?

Insert an indwelling urinary catheter to straight drainage

Schedule intermittent catheterization every 2 to 4 hours

Perform a straight catheterization every 8 hours while awake

Perform Crede’s maneuver to the lower abdomen before the client voids.

Intermittent catheterization should begin every 2 to 4 hours early in the treatment. When residual volume is less than 400 ml. the schedule may advance to every 4 to 6 hours.Options A and C: Indwelling catheters may predispose the client to infection and are removed as soon as possible.Option D: Crede’s maneuver is not used on people with spinal cord injury.

Explanation

Intermittent catheterization should begin every 2 to 4 hours early in the treatment. When residual volume is less than 400 ml. the schedule may advance to every 4 to 6 hours.Options A and C: Indwelling catheters may predispose the client to infection and are removed as soon as possible.Option D: Crede’s maneuver is not used on people with spinal cord injury.

8. A client is admitted to the ER for head trauma is diagnosed with an epidural hematoma. The underlying cause of epidural hematoma is usually related to which of the following conditions?

Laceration of the middle meningeal artery

Rupture of the carotid artery

Thromboembolism from a carotid artery

Venous bleeding from the arachnoid space

Epidural hematoma or extradural hematoma is usually caused by laceration of the middle meningeal artery.Options B and C: An embolic stroke is a thromboembolism from a carotid artery that ruptures.Option D: Venous bleeding from the arachnoid space is usually observed with a subdural hematoma.

Explanation

Epidural hematoma or extradural hematoma is usually caused by laceration of the middle meningeal artery.Options B and C: An embolic stroke is a thromboembolism from a carotid artery that ruptures.Option D: Venous bleeding from the arachnoid space is usually observed with a subdural hematoma.

9. Which of the following conditions indicates that spinal shock is resolving in a client with C7 quadriplegia?

Absence of pain sensation in chest

Spasticity

Spontaneous respirations

Urinary continence

Spasticity. the return of reflexes. is a sign of resolving shock. Spinal or neurogenic shock is characterized by hypotension. bradycardia. dry skin. flaccid paralysis. or the absence of reflexes below the level of injury.Option A: The absence of pain sensation in the chest doesn’t apply to spinal shock.Option C: Spinal shock descends from the injury. and respiratory difficulties occur at C4 and above.

Explanation

Spasticity. the return of reflexes. is a sign of resolving shock. Spinal or neurogenic shock is characterized by hypotension. bradycardia. dry skin. flaccid paralysis. or the absence of reflexes below the level of injury.Option A: The absence of pain sensation in the chest doesn’t apply to spinal shock.Option C: Spinal shock descends from the injury. and respiratory difficulties occur at C4 and above.

10. A nurse assesses a client who has episodes of autonomic dysreflexia. Which of the following conditions can cause autonomic dysreflexia?

Headache

Lumbar spinal cord injury

Neurogenic shock

Noxious stimuli

Noxious stimuli. such as a full bladder. fecal impaction. or a decubitus ulcer. may cause autonomic dysreflexia.Option A: A headache is a symptom of autonomic dysreflexia. not a cause.Option B: Autonomic dysreflexia is most commonly seen with injuries at T10 or above.Option C: Neurogenic shock isn’t a cause of dysreflexia.

Explanation

Noxious stimuli. such as a full bladder. fecal impaction. or a decubitus ulcer. may cause autonomic dysreflexia.Option A: A headache is a symptom of autonomic dysreflexia. not a cause.Option B: Autonomic dysreflexia is most commonly seen with injuries at T10 or above.Option C: Neurogenic shock isn’t a cause of dysreflexia.