Medical Surgery Cervical Spinal Cord Injury Trigeminal Neuralgia Quiz

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Medical – Surgical Final Dec 2018 – 9

Low back pain

17. A client with a history of prostate cancer is in the clinic and reports

new onset of severe low back pain. What action by the nurse is most

important?

a. Assess the client’s gait and balance.

b. Ask the client about the ease of urine flow.

c. Document the report completely.

d. Inquire about the client’s job risks.

ANS: A

This client has manifestations of spinal cord

compression, which can be seen with prostate cancer.

This may affect both gait and balance and urinary

function. For client safety, assessing gait and balance is

the priority. Documentation should be complete. The

client may or may not have occupational risks for low

back pain, but with his history of prostate cancer, this

should not be where the nurse starts investigating.

20. A client receiving a blood transfusion develops anxiety and low back

pain. After stopping the transfusion, what action by the nurse is most

important?

a. Documenting the events in the client’s medical record

b. Double-checking the client and blood product identification

c. Placing the client on strict bedrest until the pain subsides

d. Reviewing the clients medical record for known allergies.

ANS: B

This client had a hemolytic transfusion reaction, most

commonly caused by blood type or Rh incompatibility.

The nurse should double-check all identifying

information for both the client and blood type.

Documentation occurs after the client is stable. Bedrest

may or may not be needed. Allergies to medications or

environmental items is not related.

1. A nurse promotes the prevention of lower back pain by teaching clients

at a community center. Which instruction should the nurse include in this

education?

a. Participate in an exercise program to strengthen muscles.

b. Purchase a mattress that allows you to adjust the firmness.

c. Wear flat instead of high-heeled shoes to work each day.

d. Keep your weight within 20% of your ideal body weight.

ANS: A

Exercise can strengthen back muscles, reducing the

incidence of low back pain. The other options will not

prevent low back pain.

4. A nurse assesses clients at a community center. Which client is at

greatest risk for lower back pain?

a. A 24-year-old female who is 25 weeks pregnant

b. A 36-year-old male who uses ergonomic techniques

c. A 45-year-old male with osteoarthritis

d. A 53-year-old female who uses a walker.

ANS: C

Osteoarthritis causes changes to support structures,

increasing the client’s risk for low back pain. The other

clients are not at high risk.

Diskectomy

3. A nurse assesses a client who is recovering from a diskectomy 6 hours

ago. Which assessment finding should the nurse address first?

a. Sleepy but arouses to voice

b. Dry and cracked oral mucosa

c. Pain present in lower back

d. Bladder palpated above pubis

ANS: D

A distended bladder may indicate damage to the sacral

spinal nerves. The other findings require the nurse to

provide care but are not the priority or a complication

of the procedure.

6. A nurse assesses a client who is recovering from anterior cervical

diskectomy and fusion. Which complication should alert the nurse to

urgently communicate with the health care provider?

a. Auscultated stridor

b. Weak pedal pulses

c. Difficulty swallowing

d. Inability to shrug shoulders

ANS: A

Postoperative swelling can narrow the trachea, cause a

partial airway obstruction, and manifest as stridor. The

client may also have trouble swallowing, but

maintaining an airway takes priority. Weak pedal pulses

and an inability to shrug the shoulders are not

complications of this surgery.

Medical – Surgical Final Dec 2018 – 9

Autonomic dysreflexia

7. A nurse assesses a client with a spinal cord injury at level T5. The clients

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?

a. Initiate oxygen via a nasal cannula.

b. Place the client in a supine position.

c. Palpate the bladder for distention.

d. Administer a prescribed beta blocker.

ANS: C

The client is manifesting symptoms of autonomic

dysreflexia. Common causes include bladder distention,

tight clothing, increased room temperature, and fecal

impaction. If persistent, the client could experience

neurologic injury. Precipitating conditions should be

eliminated, and the physician notified. The other actions

would not be appropriate.

Cervical spinal cord injury

8. 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?

a. Assess level of consciousness.

b. Obtain vital signs.

c. Administer oxygen therapy.

d. Evaluate respiratory status.

ANS: D

The priority for a client with a spinal cord injury is

assessment of respiratory status and airway patency.

Clients with cervical spine injuries are particularly prone

to respiratory compromise and may even require

intubation. The other assessments should be performed

after airway and breathing are assessed.

Lower motor neuron lesion

Guillain-Barré syndrome (GBS)

1. A client is admitted with Guillain-Barr syndrome (GBS). What

assessment takes priority?

a. Bladder control

b. Cognitive perception

c. Respiratory system

d. Sensory functions

ANS: C

Clients with GBS have muscle weakness, possibly to the

point of paralysis. If respiratory muscles are paralyzed,

the client may need mechanical ventilation, so the

respiratory system is the priority. The nurse will

complete urinary, cognitive, and sensory assessments as

part of a thorough evaluation.

Myasthenia gravis

5. A client is taking long-term corticosteroids for myasthenia gravis. What

teaching is most important?

a. Avoid large crowds and people who are ill.

b. Check blood sugars four times a day.

c. Use two forms of contraception.

d. Wear properly fitting socks and shoes.

ANS: A

Corticosteroids reduce immune function, so clients

taking these medications must avoid being exposed to

illness. Long-term use can lead to secondary diabetes,

but the client would not need to start checking blood

glucose unless diabetes had been detected.

Corticosteroids do not affect the effectiveness of

contraception. Wearing well-fitting shoes would be

important to avoid injury, but not just because the client

takes corticosteroids.

10. A nurse teaches a client with a lower motor neuron lesion who wants

to achieve bladder control. Which statement should the nurse include in

this client teaching?

a. Stroke the inner aspect of your thigh to initiate voiding.

b. Use a clean technique for intermittent catheterization.

c. Implement digital anal stimulation when your bladder is full.

d. Tighten your abdominal muscles to stimulate urine flow.

ANS: D

In clients with lower motor neuron problems such as

spinal cord injury, performing a Valsalva maneuver or

tightening the abdominal muscles are interventions that

can initiate voiding. Stroking the inner aspect of the

thigh may initiate voiding in a client who has an upper

motor neuron problem. Intermittent catheterization and

digital anal stimulation do not initiate voiding or

bladder control.

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Medical – Surgical Final Dec 2018 – 9th ED Low back pain 17. A client with a history of prostate cancer is in the clinic and reports new onset of severe low back pain. What action by the nurse is most important? a. Assess the client’s gait and balance. b. Ask the client about the ease of urine flow. c. Document the report completely. d. Inquire about the client’s job risks. ANS: A 20. A client receiving a blood transfusion develops anxiety and low back pain. After stopping the transfusion, what action by the nurse is most important? a. Documenting the events in the client’s medical record b. Double-checking the client and blood product identification c. Placing the client on strict bedrest until the pain subsides d. Reviewing the clients medical record for known allergies. ANS: B 1. A nurse promotes the prevention of lower back pain by teaching clients at a community center. Which instruction should the nurse include in this education? a. Participate in an exercise program to strengthen muscles. b. Purchase a mattress that allows you to adjust the firmness. c. Wear flat instead of high-heeled shoes to work each day. d. Keep your weight within 20% of your ideal body weight. ANS: A 4. A nurse assesses clients at a community center. Which client is at greatest risk for lower back pain? a. A 24-year-old female who is 25 weeks pregnant b. A 36-year-old male who uses ergonomic techniques c. A 45-year-old male with osteoarthritis d. A 53-year-old female who uses a wa ...
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