Nervous System | Neurological Disorders NCLEX Quiz 48

1. A client with a spinal cord injury suddenly experiences an episode of autonomic dysreflexia. After checking the client's vital signs. list in order of priority. the nurse's actions (Number 1 being the first priority and number 5 being the last priority).

Check for bladder distention

Raise the head of the bed

Contact the physician

Loosen tight clothing on the client

Administer an antihypertensive medication

Autonomic dysreflexia is characterized by severe hypertension. bradycardia. severe headache. nasal stuffiness. and flushing. The cause is a noxious stimulus. most often a distended bladder or constipation. Autonomic dysreflexia is a neurological emergency and must be treated promptly to prevent a hypertensive stroke. Immediate nursing actions are to sit the client up in bed in a high-Fowler’s position and remove the noxious stimulus. The nurse should loosen any tight clothing and then check for bladder distention. If the client has a foley catheter. the nurse should check for kinks in the tubing. The nurse also would check for a fecal impaction and disimpact if necessary. The physician is contacted especially if these actions do not relieve the signs and symptoms. Antihypertensive medications may be prescribed by the physician to minimize cerebral hypertension.

Explanation

Autonomic dysreflexia is characterized by severe hypertension. bradycardia. severe headache. nasal stuffiness. and flushing. The cause is a noxious stimulus. most often a distended bladder or constipation. Autonomic dysreflexia is a neurological emergency and must be treated promptly to prevent a hypertensive stroke. Immediate nursing actions are to sit the client up in bed in a high-Fowler’s position and remove the noxious stimulus. The nurse should loosen any tight clothing and then check for bladder distention. If the client has a foley catheter. the nurse should check for kinks in the tubing. The nurse also would check for a fecal impaction and disimpact if necessary. The physician is contacted especially if these actions do not relieve the signs and symptoms. Antihypertensive medications may be prescribed by the physician to minimize cerebral hypertension.

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2. A 20-year-old client who fell approximately 30' is unresponsive and breathless. A cervical spine injury is suspected. How should the first-responder open the client's airway for rescue breathing?

By inserting a nasopharyngeal airway

By inserting a oropharyngeal airway

By performing a jaw-thrust maneuver

By performing the head-tilt. chin-lift maneuver

If the client has a suspected cervical spine injury. a jaw-thrust maneuver should be used to open the airway.Options A and B: If the tongue or relaxed throat muscles are obstructing the airway. a nasopharyngeal or oropharyngeal airway can be inserted; however. the client must have spontaneous respirations when the airway is open.Option D: The head-tilt. chin-lift maneuver requires neck hyperextension. which can worsen the cervical spine injury.

Explanation

If the client has a suspected cervical spine injury. a jaw-thrust maneuver should be used to open the airway.Options A and B: If the tongue or relaxed throat muscles are obstructing the airway. a nasopharyngeal or oropharyngeal airway can be inserted; however. the client must have spontaneous respirations when the airway is open.Option D: The head-tilt. chin-lift maneuver requires neck hyperextension. which can worsen the cervical spine injury.

3. The client with a head injury has been urinating copious amounts of dilute urine through the Foley catheter. The client's urine output for the previous shift was 3000 ml. The nurse implements a new physician order to administer:

Desmopressin (DDAVP. Stimate)

Dexamethasone (Decadron)

Ethacrynic acid (Edecrin)

Mannitol (Osmitrol)

A complication of a head injury is diabetes insipidus. which can occur with insult to the hypothalamus. the antidiuretic storage vesicles. or the posterior pituitary gland. Urine output that exceeds 9 L per day generally requires treatment with desmopressin.Option B: Dexamethasone. a glucocorticoid. is administered to treat cerebral edema. This medication may be ordered for the head injured patient.Options C and D: Ethacrynic acid and mannitol are diuretics. which would be contraindicated.

Explanation

A complication of a head injury is diabetes insipidus. which can occur with insult to the hypothalamus. the antidiuretic storage vesicles. or the posterior pituitary gland. Urine output that exceeds 9 L per day generally requires treatment with desmopressin.Option B: Dexamethasone. a glucocorticoid. is administered to treat cerebral edema. This medication may be ordered for the head injured patient.Options C and D: Ethacrynic acid and mannitol are diuretics. which would be contraindicated.

4. The nurse is caring for a client who suffered a spinal cord injury 48 hours ago. The nurse monitors for GI complications by assessing for:

A flattened abdomen

Hematest positive nasogastric tube drainage

Hyperactive bowel sounds

A history of diarrhea

Development of a stress ulcer can be detected by hematest positive NG tube aspirate or stool.Options A and C: After spinal cord injury. the client can develop paralytic ileus. which is characterized by the absence of bowel sounds and abdominal distention.Option D: A history of diarrhea is irrelevant.

Explanation

Development of a stress ulcer can be detected by hematest positive NG tube aspirate or stool.Options A and C: After spinal cord injury. the client can develop paralytic ileus. which is characterized by the absence of bowel sounds and abdominal distention.Option D: A history of diarrhea is irrelevant.

5. The nurse is evaluating neurological signs of the male client in spinal shock following spinal cord injury. Which of the following observations by the nurse indicates that spinal shock persists?

Positive reflexes

Hyperreflexia

Inability to elicit a Babinski’s reflex

Reflex emptying of the bladder

Resolution of spinal shock is occurring when there is a return of reflexes (especially flexors to noxious cutaneous stimuli). a state of hyperreflexia rather than flaccidity. reflex emptying of the bladder. and a positive Babinski’s reflex.

Explanation

Resolution of spinal shock is occurring when there is a return of reflexes (especially flexors to noxious cutaneous stimuli). a state of hyperreflexia rather than flaccidity. reflex emptying of the bladder. and a positive Babinski’s reflex.

6. The nurse is planning care for the client in spinal shock. Which of the following actions would be least helpful in minimizing the effects of vasodilation below the level of the injury?

Monitoring vital signs before and during position changes

Using vasopressor medications as prescribed

Moving the client quickly as one unit

Applying Teds or compression stockings.

Reflex vasodilation below the level of the spinal cord injury places the client at risk for orthostatic hypotension. which may be profound.Option A: Measures to minimize this include measuring vital signs before and during position changes. use of a tilt-table with early mobilization. and changing the client’s position slowly.Option B: Vasopressor medications are administered per protocol.Option D: Venous pooling can be reduced by using Teds (compression stockings) or pneumatic boots.

Explanation

Reflex vasodilation below the level of the spinal cord injury places the client at risk for orthostatic hypotension. which may be profound.Option A: Measures to minimize this include measuring vital signs before and during position changes. use of a tilt-table with early mobilization. and changing the client’s position slowly.Option B: Vasopressor medications are administered per protocol.Option D: Venous pooling can be reduced by using Teds (compression stockings) or pneumatic boots.

7. A client with a spinal cord injury is prone to experiencing autonomic dysreflexia. The nurse would avoid which of the following measures to minimize the risk of recurrence?

Strict adherence to a bowel retraining program

Limiting bladder catheterization to once every 12 hours

Keeping the linen wrinkle-free under the client

Preventing unnecessary pressure on the lower limbs

The most frequent cause of autonomic dysreflexia is a distended bladder. Straight catheterization should be done every 4 to 6 hours. and Foley catheters should be checked frequently to prevent kinks in the tubing.Option A: Constipation and fecal impaction are other causes. so maintaining bowel regularity is important.Options C and D: Other causes include stimulation of the skin from tactile. thermal. or painful stimuli. The nurse administers care to minimize risk in these areas.

Explanation

The most frequent cause of autonomic dysreflexia is a distended bladder. Straight catheterization should be done every 4 to 6 hours. and Foley catheters should be checked frequently to prevent kinks in the tubing.Option A: Constipation and fecal impaction are other causes. so maintaining bowel regularity is important.Options C and D: Other causes include stimulation of the skin from tactile. thermal. or painful stimuli. The nurse administers care to minimize risk in these areas.

8. The nurse is caring for the client in the ER following a head injury. The client momentarily lost consciousness at the time of the injury and then regained it. The client now has lost consciousness again. The nurse takes quick action. knowing this is compatible with:

Skull fracture

Concussion

Subdural hematoma

Epidural hematoma

The changes in neurological signs from an epidural hematoma begin with a loss of consciousness as arterial blood collects in the epidural space and exerts pressure. The client regains consciousness as the cerebral spinal fluid is reabsorbed rapidly to compensate for the rising intracranial pressure. As the compensatory mechanisms fail. even small amounts of additional blood can cause the intracranial pressure to rise rapidly. and the client’s neurological status deteriorates quickly.

Explanation

The changes in neurological signs from an epidural hematoma begin with a loss of consciousness as arterial blood collects in the epidural space and exerts pressure. The client regains consciousness as the cerebral spinal fluid is reabsorbed rapidly to compensate for the rising intracranial pressure. As the compensatory mechanisms fail. even small amounts of additional blood can cause the intracranial pressure to rise rapidly. and the client’s neurological status deteriorates quickly.

9. The nurse is caring for a client with a T5 complete spinal cord injury. Upon assessment. the nurse notes flushed skin. diaphoresis above the T5. and a blood pressure of 162/96. The client reports a severe. pounding headache. Which of the following nursing interventions would be appropriate for this client? Select all that apply.

Elevate the HOB to 90 degrees

Loosen constrictive clothing

Use a fan to reduce diaphoresis

Assess for bladder distention and bowel impaction

Administer antihypertensive medication

Place the client in a supine position with legs elevated

The client has signs and symptoms of autonomic dysreflexia. The potentially life-threatening condition is caused by an uninhibited response from the sympathetic nervous system resulting from a lack of control over the autonomic nervous system. The nurse should immediately elevate the HOB to 90 degrees and place extremities dependently to decrease venous return to the heart and increase venous return from the brain. Because tactile stimuli can trigger autonomic dysreflexia. any constrictive clothing should be loosened. The nurse should also assess for distended bladder and bowel impaction. which may trigger autonomic dysreflexia. and correct any problems. Elevated blood pressure is the most life-threatening complication of autonomic dysreflexia because it can cause stroke. MI. or seizures. If removing the triggering event doesn’t reduce the client’s blood pressure. IV antihypertensives should be administered.Option C: A fan shouldn’t be used because cold drafts may trigger autonomic dysreflexia.

Explanation

The client has signs and symptoms of autonomic dysreflexia. The potentially life-threatening condition is caused by an uninhibited response from the sympathetic nervous system resulting from a lack of control over the autonomic nervous system. The nurse should immediately elevate the HOB to 90 degrees and place extremities dependently to decrease venous return to the heart and increase venous return from the brain. Because tactile stimuli can trigger autonomic dysreflexia. any constrictive clothing should be loosened. The nurse should also assess for distended bladder and bowel impaction. which may trigger autonomic dysreflexia. and correct any problems. Elevated blood pressure is the most life-threatening complication of autonomic dysreflexia because it can cause stroke. MI. or seizures. If removing the triggering event doesn’t reduce the client’s blood pressure. IV antihypertensives should be administered.Option C: A fan shouldn’t be used because cold drafts may trigger autonomic dysreflexia.

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10. The nurse is caring for a client admitted with spinal cord injury. The nurse minimizes the risk of compounding the injury most effectively by:

Keeping the client on a stretcher

Logrolling the client on a firm mattress

Logrolling the client on a soft mattress

Placing the client on a Stryker frame

Spinal immobilization is necessary after spinal cord injury to prevent further damage and insult to the spinal cord. Whenever possible. the client is placed on a Stryker frame. which allows the nurse to turn the client to prevent complications of immobility. while maintaining alignment of the spine. If a Stryker frame is not available. a firm mattress with a bed board should be used.

Explanation

Spinal immobilization is necessary after spinal cord injury to prevent further damage and insult to the spinal cord. Whenever possible. the client is placed on a Stryker frame. which allows the nurse to turn the client to prevent complications of immobility. while maintaining alignment of the spine. If a Stryker frame is not available. a firm mattress with a bed board should be used.