nan Spine & CNS Disorder Care Full Test Bank Ch.43 - Medical Surgical Nursing 7e | Test Bank by LeMone, Burke, Bauldoff by LeMone, Burke, Gerene Bauldoff. DOCX document preview.
LeMone & Burke's Medical-Surgical Nursing, 7e (Bauldoff/Gubrud/Carno)
Chapter 43 Nursing Care of Patients with Spinal Cord Disorders and CNS Infections
1) A victim of a motor vehicle crash has an acute cervical spinal cord injury. Which problem should the nurse identify as the priority for this patient?
1. Fluid maintenance
2. Changes in mobility
3. Problems with the airway
4. Altered blood flow
Page Ref: 1605
Cognitive Level: Analyzing
Client Need & Sub: Physiological Integrity: Reduction of Risk Potential
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning
Learning Outcome: 43.1 Describe the pathophysiology and manifestations of spinal cord injuries, and outline the interprofessional care and nursing care of patients with these disorders.
MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with spinal cord disorders and CNS infections.
2) A patient recovering from a spinal cord injury (SCI) is experiencing gastric distress. Which medication should the nurse expect to be prescribed for this patient?
1. Omeprazole (Prilosec)
2. Dopamine (Intropin)
3. Baclofen (Lioresal)
4. Dantrolene (Dantrium)
Page Ref: 1603
Cognitive Level: Applying
Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning
Learning Outcome: 43.1 Describe the pathophysiology and manifestations of spinal cord injuries, and outline the interprofessional care and nursing care of patients with these disorders.
MNL Learning Outcome: 2. Consider intraprofessional care for patients with spinal cord disorders and CNS infections.
3) A patient with a spinal cord injury at the T1 level complains of a severe headache and an "anxious feeling." Which is the most appropriate initial reaction by the nurse?
1. Calm the patient and make the environment soothing.
2. Assess for a full bladder.
3. Notify the healthcare provider.
4. Prepare the patient for diagnostic radiography.
Page Ref: 1601
Cognitive Level: Applying
Client Need & Sub: Physiological Integrity: Reduction of Risk Potential
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 43.1 Describe the pathophysiology and manifestations of spinal cord injuries, and outline the interprofessional care and nursing care of patients with these disorders.
MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with spinal cord disorders and CNS infections.
4) A school nurse is called after a student falls down a flight of stairs. The student is breathing but unconscious. After calling the ambulance, what should the nurse do?
1. Assess the neck for movement.
2. Place the patient on the side to prevent aspiration.
3. Immobilize the neck, securing the head.
4. Try to rouse the patient by gently shaking the shoulders.
Page Ref: 1602
Cognitive Level: Applying
Client Need & Sub: Physiological Integrity: Reduction of Risk Potential
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 43.1 Describe the pathophysiology and manifestations of spinal cord injuries, and outline the interprofessional care and nursing care of patients with these disorders.
MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with spinal cord disorders and CNS infections.
5) The healthcare provider prescribes 2.5 mg IV of morphine sulfate to be administered to a patient with a ruptured intervertebral disk whose pain has not been controlled with NSAIDs and muscle relaxants. The nurse has a 1 milliliter (mL) syringe containing 10 mg of morphine sulfate. How many milliliters of morphine sulfate does the nurse need to withdraw from the syringe?
________ mL
Calculate the exact dosage.
Page Ref: 1613
Cognitive Level: Applying
Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 43.1 Describe the pathophysiology and manifestations of spinal cord injuries, and outline the interprofessional care and nursing care of patients with these disorders.
MNL Learning Outcome: 2. Consider intraprofessional care for patients with spinal cord disorders and CNS infections.
6) The healthcare provider prescribes 15 mg IV of ketorolac (Toradol) for a patient who has recently undergone a spinal fusion. The nurse has a 5-milliliter (mL) ampule containing 60 mg of ketorolac. How many milliliters of ketorolac does the nurse need to withdraw from the syringe?
________ mL
Calculate the exact dose.
Page Ref: 1613
Cognitive Level: Applying
Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 43.1 Describe the pathophysiology and manifestations of spinal cord injuries, and outline the interprofessional care and nursing care of patients with these disorders.
MNL Learning Outcome: 2. Consider intraprofessional care for patients with spinal cord disorders and CNS infections.
7) A hospitalized patient with a C7 cord injury yells, "I can't feel my legs anymore." Which is the most appropriate action by the nurse?
1. Remind the patient of her injury and try to comfort her.
2. Call the healthcare provider and ask for a radiologic evaluation.
3. Prepare the patient for surgery because the injury is worsening.
4. Explain that this could be a common, temporary problem.
Page Ref: 1600
Cognitive Level: Applying
Client Need & Sub: Physiological Integrity: Physiological Adaptation
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.4. Communicate effectively with all members of the healthcare team, including the patient and the patient's support network | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Communication and Documentation
Learning Outcome: 43.1 Describe the pathophysiology and manifestations of spinal cord injuries, and outline the interprofessional care and nursing care of patients with these disorders.
MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with spinal cord disorders and CNS infections.
8) A nurse witnesses a motor vehicle accident (MVA) while off duty. Upon approaching the scene, the nurse observes a victim lying on the ground after being ejected from the vehicle. Arrange the actions the nurse should take in the correct order, starting with the first. All options must be used.
Choice 1. Check the victim's breathing.
Choice 2. Check the victim's pulse.
Choice 3. Check the victim's airway.
Choice 4. Immobilize the spine.
Choice 5. Check for the victim's responsiveness.
Page Ref: 1602
Cognitive Level: Applying
Client Need & Sub: Physiological Integrity: Reduction of Risk Potential
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 43.1 Describe the pathophysiology and manifestations of spinal cord injuries, and outline the interprofessional care and nursing care of patients with these disorders.
MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with spinal cord disorders and CNS infections.
9) A patient with a spinal cord injury (SCI) is placed in traction. Which action should the nurse include when caring for this patient? Select all that apply.
1. Modifying the traction weights as needed
2. Assessing the patient's skin integrity
3. Applying the traction upon admission
4. Administering pain medication
5. Providing passive range of motion
Page Ref: 1605-1606
Cognitive Level: Applying
Client Need & Sub: Physiological Integrity: Reduction of Risk Potential
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 43.1 Describe the pathophysiology and manifestations of spinal cord injuries, and outline the interprofessional care and nursing care of patients with these disorders.
MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with spinal cord disorders and CNS infections.
10) The nurse is educating a patient and the family about different types of stabilization devices. Which statement indicates that the patient understands the benefit of using a halo fixation device instead of Gardner-Wells tongs?
1. "I will have less pain if I use the halo device."
2. "The halo device will allow me to get out of bed."
3. "I am less likely to get an infection with the halo device."
4. "The halo device does not have to stay in place as long."
Page Ref: 1603
Cognitive Level: Analyzing
Client Need & Sub: Physiological Integrity: Reduction of Risk Potential
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.9. Monitor client outcomes to evaluate the effectiveness of psychobiological interventions | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Evaluation/Teaching/Learning
Learning Outcome: 43.1 Describe the pathophysiology and manifestations of spinal cord injuries, and outline the interprofessional care and nursing care of patients with these disorders.
MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with spinal cord disorders and CNS infections.
11) A patient with a spinal cord injury was given IV dexamethasone (Decadron) after arriving in the emergency department. What assessment finding should the nurse attribute to the steroid medication?
1. Hypoglycemia
2. Less spinal shock
3. Urinary retention
4. Muscle spasms
Page Ref: 1602
Cognitive Level: Analyzing
Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 43.1 Describe the pathophysiology and manifestations of spinal cord injuries, and outline the interprofessional care and nursing care of patients with these disorders.
MNL Learning Outcome: 2. Consider intraprofessional care for patients with spinal cord disorders and CNS infections.
12) The nurse is caring for a patient recovering from a laminectomy. Which action should the nurse take to prevent skin breakdown in this patient?
1. Provide an air mattress.
2. Place pillows under the patient to help with turns.
3. Teach to grasp the side rail to turn.
4. Use log rolling to turn to the side.
Page Ref: 1613
Cognitive Level: Applying
Client Need & Sub: Physiological Integrity: Reduction of Risk Potential
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 43.1 Describe the pathophysiology and manifestations of spinal cord injuries, and outline the interprofessional care and nursing care of patients with these disorders.
MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with spinal cord disorders and CNS infections.
13) The nurse is planning care for a patient recovering from spinal fusion surgery. What should the nurse identify as a goal of care for this patient? Select all that apply.
1. Maximizing comfort
2. Controlling pain
3. Promoting body alignment
4. Preventing injury
5. Promoting nutritional intake
Page Ref: 1613
Cognitive Level: Applying
Client Need & Sub: Physiological Integrity: Reduction of Risk Potential
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning
Learning Outcome: 43.1 Describe the pathophysiology and manifestations of spinal cord injuries, and outline the interprofessional care and nursing care of patients with these disorders.
MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with spinal cord disorders and CNS infections.
14) The nurse is preparing an educational session about spinal cord injury (SCI) prevention for a community group. What patient example should the nurse use to explain the risk factors for this type of injury?
1. 18-year-old male with a prior arrest for driving while intoxicated (DWI)
2. 28-year-old female with a history of substance abuse
3. 50-year-old female with osteoporosis
4. 35-year-old male who coaches a soccer team
Page Ref: 1625
Cognitive Level: Applying
Client Need & Sub: Health Promotion and Maintenance: High Risk Behaviors
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning
Learning Outcome: 43.1 Describe the pathophysiology and manifestations of spinal cord injuries, and outline the interprofessional care and nursing care of patients with these disorders.
MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with spinal cord disorders and CNS infections.
15) The nurse understands that when the spinal cord is injured, ischemia and edema result. How should the nurse explain to the patient the reason that the extent of injury cannot be determined for several days to a week?
1. "Tissue repair does not begin for 72 hours."
2. "The edema extends the level of injury two cord segments above and below the affected level."
3. "Neurons need time to regenerate, so stating the extent of injury early is not predictive of how the patient progresses."
4. "Necrosis of gray and white matter does not occur until days after the injury."
Page Ref: 1598
Cognitive Level: Applying
Client Need & Sub: Physiological Integrity: Physiological Adaptation
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning
Learning Outcome: 43.1 Describe the pathophysiology and manifestations of spinal cord injuries, and outline the interprofessional care and nursing care of patients with these disorders.
MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with spinal cord disorders and CNS infections.
16) A patient with a spinal cord injury is recovering from spinal shock. What can occur if the patient develops a full bladder?
1. Autonomic dysreflexia
2. Autonomic crisis
3. Autonomic shutdown
4. Autonomic failure
Page Ref: 1601
Cognitive Level: Analyzing
Client Need & Sub: Physiological Integrity: Reduction of Risk Potential
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 43.1 Describe the pathophysiology and manifestations of spinal cord injuries, and outline the interprofessional care and nursing care of patients with these disorders.
MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with spinal cord disorders and CNS infections.
17) While caring for a patient with a spinal cord injury (SCI), the nurse elevates the head of the bed, removes compression stockings, and continues to assess vital signs every 2 to 3 minutes while searching for the cause in order to prevent loss of consciousness or death. By completing these interventions, which health problem is the nurse preventing as the most dangerous complication of autonomic dysreflexia?
1. Hypoxia
2. Bradycardia
3. Elevated blood pressure
4. Tachycardia
Page Ref: 1606
Cognitive Level: Analyzing
Client Need & Sub: Physiological Integrity: Reduction of Risk Potential
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 43.1 Describe the pathophysiology and manifestations of spinal cord injuries, and outline the interprofessional care and nursing care of patients with these disorders.
MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with spinal cord disorders and CNS infections.
18) A patient with a secondary metastatic spinal cord tumor is scheduled for surgery. What should the nurse recognize as the goal of surgery for this patient?
1. Complete removal of the tumor and affected spinal cord tissue
2. Eradication of the tumor with excision and drainage
3. Tumor excision to reduce cord compression
4. Exploration to visualize the tumor and obtain a biopsy
Page Ref: 1617
Cognitive Level: Analyzing
Client Need & Sub: Physiological Integrity: Reduction of Risk Potential
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning
Learning Outcome: 43.1 Describe the pathophysiology and manifestations of spinal cord injuries, and outline the interprofessional care and nursing care of patients with these disorders.
MNL Learning Outcome: 2. Consider intraprofessional care for patients with spinal cord disorders and CNS infections.
19) A patient with a spinal cord injury (SCI) has complete paralysis of both upper and lower extremities. Which term should the nurse use when documenting this patient's status?
1. Hemiplegia
2. Paresthesia
3. Paraplegia
4. Quadriplegia
Page Ref: 1599
Cognitive Level: Applying
Client Need & Sub: Physiological Integrity: Reduction of Risk Potential
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.4. Communicate effectively with all members of the healthcare team, including the patient and the patient's support network | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Assessment/Communication and Documentation
Learning Outcome: 43.1 Describe the pathophysiology and manifestations of spinal cord injuries, and outline the interprofessional care and nursing care of patients with these disorders.
MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with spinal cord disorders and CNS infections.
20) A patient with a spinal cord injury has a blood pressure of 90/60 mmHg, flaccid paralysis on the right, absent bowel sounds, zero urine output, and palpation of a distended bladder. Which health problem should the nurse suspect is occurring with this patient?
1. Paralysis
2. Spinal shock
3. High cervical injury
4. Temporary hypovolemia
Page Ref: 1600
Cognitive Level: Analyzing
Client Need & Sub: Physiological Integrity: Physiological Adaptation
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 43.1 Describe the pathophysiology and manifestations of spinal cord injuries, and outline the interprofessional care and nursing care of patients with these disorders.
MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with spinal cord disorders and CNS infections.
21) An unconscious patient receiving emergency care following a motor vehicle crash has a possible spinal cord injury. What guideline for emergency care should be followed? Select all that apply.
1. Immobilize the patient's neck using rolled towels or a cervical collar.
2. Place the patient in a supine position.
3. Place the patient on a ventilator.
4. Elevate the head of the bed.
5. Secure the patient's head with a belt or tape secured to the stretcher.
Page Ref: 1602
Cognitive Level: Applying
Client Need & Sub: Physiological Integrity: Reduction of Risk Potential
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; Practice-Know-How; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 43.1 Describe the pathophysiology and manifestations of spinal cord injuries, and outline the interprofessional care and nursing care of patients with these disorders.
MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with spinal cord disorders and CNS infections.
22) The nurse suspects that a patient with a spinal cord injury is experiencing autonomic dysreflexia. Which finding will help the nurse determine the cause for this health problem? Select all that apply.
1. Hypertension
2. Kinked catheter tubing
3. Respiratory wheezes and stridor
4. Diarrhea
5. Fecal impaction
Page Ref: 1606
Cognitive Level: Analyzing
Client Need & Sub: Physiological Integrity: Reduction of Risk Potential
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 43.1 Describe the pathophysiology and manifestations of spinal cord injuries, and outline the interprofessional care and nursing care of patients with these disorders.
MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with spinal cord disorders and CNS infections.
23) An industrial nurse is conducting a class on ways to prevent back pain. What should the nurse include when teaching about lifting heavy objects? Select all that apply.
1. Spread the feet apart to broaden the base of support.
2. Use the legs to push when lifting.
3. Stand as closely as possible to the object to be moved.
4. Squat and use the thigh muscles.
5. Bend at the waist over the center of gravity.
Page Ref: 1615
Cognitive Level: Applying
Client Need & Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning
Learning Outcome: 43.1 Describe the pathophysiology and manifestations of spinal cord injuries, and outline the interprofessional care and nursing care of patients with these disorders.
MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with spinal cord disorders and CNS infections.
24) The nurse is preparing an educational program on bacterial meningitis for a group of community members. Which group should the nurse identify as being at greatest risk for this infection? Select all that apply.
1. Older adults
2. Pregnant women
3. Military recruits
4. College students
5. Low-income individuals
Page Ref: 1618
Cognitive Level: Applying
Client Need & Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning
Learning Outcome: 43.2 Describe the pathophysiology and manifestations of central nervous system infections, and outline the interprofessional care and nursing care of patients with these disorders.
MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with spinal cord disorders and CNS infections.
25) A patient had the poliomyelitis virus decades ago. What should the nurse expect when assessing the patient with post-poliomyelitis syndrome now?
1. Progressive muscle weakness, fatigue, and pain; muscle atrophy and scoliosis
2. A new outbreak of polio and the need for a new immunization
3. Respiratory complications that must be quarantined
4. Active polio
Page Ref: 1624
Cognitive Level: Applying
Client Need & Sub: Physiological Integrity: Physiological Adaptation
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 43.2 Describe the pathophysiology and manifestations of central nervous system infections, and outline the interprofessional care and nursing care of patients with these disorders.
MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with spinal cord disorders and CNS infections.
26) A patient being treated for cat scratches is concerned about tetanus. Which method should the nurse describe as a way to completely prevent the development of tetanus?
1. Active immunization
2. Debriding the bite wound
3. Passive immunization
4. Administering antibiotics immediately after a bite
Page Ref: 1623
Cognitive Level: Applying
Client Need & Sub: Physiological Integrity: Reduction of Risk Potential
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.4. Communicate effectively with all members of the healthcare team, including the patient and the patient's support network | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Communication and Documentation
Learning Outcome: 43.2 Describe the pathophysiology and manifestations of central nervous system infections, and outline the interprofessional care and nursing care of patients with these disorders.
MNL Learning Outcome: 2. Consider intraprofessional care for patients with spinal cord disorders and CNS infections.
27) A patient is admitted to the hospital with a suspected case of botulism. The nurse recognizes that which situation likely caused this infection?
1. The patient ate food contaminated with the toxin.
2. The patient came in contact with someone who had botulism.
3. The patient was injected with the poison.
4. The patient had a dirty wound that became infected with the toxin.
Page Ref: 1624
Cognitive Level: Analyzing
Client Need & Sub: Physiological Integrity: Reduction of Risk Potential
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 43.2 Describe the pathophysiology and manifestations of central nervous system infections, and outline the interprofessional care and nursing care of patients with these disorders.
MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with spinal cord disorders and CNS infections.
28) During a health fair, a participant asks why food should not be eaten from a "bulging" can. How should the nurse respond?
1. "It may be a sign that botulism toxins are present, because the food has been improperly processed and sealed."
2. "Arboviruses may be found in canned foods that appear damaged."
3. "The bacteria Clostridium tetani grows in poorly processed foods or damaged cans."
4. "Open the can, and if no bubbles, bad odor, or change in color is present, you can eat the contents."
Page Ref: 1624
Cognitive Level: Applying
Client Need & Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning
Learning Outcome: 43.2 Describe the pathophysiology and manifestations of central nervous system infections, and outline the interprofessional care and nursing care of patients with these disorders.
MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with spinal cord disorders and CNS infections.
29) A patient is experiencing symptoms of post-poliomyelitis syndrome. What should the nurse recall about this health problem?
1. The initial infection occurred in the 1940s and 1950s.
2. The patient will have muscle involvement only in muscle groups that were affected initially.
3. The patient will have few symptoms other than mild muscle and joint weakness and pain.
4. The patient had a recurrence due to receiving an oral polio vaccine booster.
Page Ref: 1624
Cognitive Level: Analyzing
Client Need & Sub: Physiological Integrity: Physiological Adaptation
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 43.2 Describe the pathophysiology and manifestations of central nervous system infections, and outline the interprofessional care and nursing care of patients with these disorders.
MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with spinal cord disorders and CNS infections.
30) A patient with protruding lumbar disks is scheduled for a laminectomy. What should the nurse instruct the patient about this surgery? Select all that apply.
1. The surgery will relieve pressure on the nerves.
2. A hollow titanium cylinder will be placed over the spine.
3. The spaces where the spinal nerves exit the canal will be enlarged.
4. The bony arch on the surface of the vertebra will be removed.
5. Wedge-shaped pieces of bone will be inserted between the vertebrae.
Page Ref: 1612
Cognitive Level: Applying
Client Need & Sub: Physiological Integrity: Reduction of Risk Potential
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning
Learning Outcome: 43.1 Describe the pathophysiology and manifestations of spinal cord injuries, and outline the interprofessional care and nursing care of patients with these disorders.
MNL Learning Outcome: 2. Consider intraprofessional care for patients with spinal cord disorders and CNS infections.
31) The nurse instructs a patient with herniated thoracic and lumbar disks about spinal fusion surgery. Which patient statements indicate that teaching has been effective? Select all that apply.
1. "Bone chips might be taken from my iliac crest bone."
2. "Holes will be drilled into my skull so that a brace can be placed."
3. "Bone chips will be wedged between the vertebrae to stabilize them."
4. "I will need to stay on bed rest because traction will be applied to my spine."
5. "A hollow titanium tube might be placed in my spine to replace a removed disk."
Page Ref: 1612
Cognitive Level: Analyzing
Client Need & Sub: Physiological Integrity: Reduction of Risk Potential
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.9. Monitor client outcomes to evaluate the effectiveness of psychobiological interventions | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Evaluation/Teaching/Learning
Learning Outcome: 43.1 Describe the pathophysiology and manifestations of spinal cord injuries, and outline the interprofessional care and nursing care of patients with these disorders.
MNL Learning Outcome: 2. Consider intraprofessional care for patients with spinal cord disorders and CNS infections.
32) A patient recovering from a laminectomy reports a pain level of 10 on a scale of 0 to 10 and believes something must be wrong because the pain is worse than it was before the surgery. How should the nurse respond?
1. "The discomfort is not pain but rather muscle spasms."
2. "I'm sure you will need more surgery, so I will be back to get you."
3. "The surgery caused edema of the nerve roots, which increases the amount of pain."
4. "Pain is an indication that something is wrong. I will contact the surgeon."
Page Ref: 1613
Cognitive Level: Applying
Client Need & Sub: Physiological Integrity: Reduction of Risk Potential
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning
Learning Outcome: 43.1 Describe the pathophysiology and manifestations of spinal cord injuries, and outline the interprofessional care and nursing care of patients with these disorders.
MNL Learning Outcome: 2. Consider intraprofessional care for patients with spinal cord disorders and CNS infections.
33) The nurse is instructing a patient with a ruptured vertebral disk on self-care measures. What should the nurse include in this teaching? Select all that apply.
1. Bend from the waist.
2. Wear low-heeled shoes.
3. Avoid twisting the back.
4. Sleep on a firm mattress.
5. Use a pillow under the knees when lying down.
Page Ref: 1615
Cognitive Level: Applying
Client Need & Sub: Physiological Integrity: Reduction of Risk Potential
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning
Learning Outcome: 43.1 Describe the pathophysiology and manifestations of spinal cord injuries, and outline the interprofessional care and nursing care of patients with these disorders.
MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with spinal cord disorders and CNS infections.
34) A patient is diagnosed with a lumbosacral spinal cord tumor. Which medication should the nurse expect to be prescribed for this patient? Select all that apply.
1. Morphine
2. Furosemide (Lasix)
3. Warfarin (Coumadin)
4. Amoxicillin (Amoxil)
5. Dexamethasone (Decadron)
Page Ref: 1616
Cognitive Level: Analyzing
Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning
Learning Outcome: 43.1 Describe the pathophysiology and manifestations of spinal cord injuries, and outline the interprofessional care and nursing care of patients with these disorders.
MNL Learning Outcome: 2. Consider intraprofessional care for patients with spinal cord disorders and CNS infections.
35) The nurse is concerned that a patient with a spinal cord tumor is developing syringomyelia. What did the nurse assess to make this clinical decision? Select all that apply.
1. Pain
2. Spasticity
3. Numbness
4. Leg weakness
5. Cool extremities
Page Ref: 1616
Cognitive Level: Analyzing
Client Need & Sub: Physiological Integrity: Reduction of Risk Potential
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 43.1 Describe the pathophysiology and manifestations of spinal cord injuries, and outline the interprofessional care and nursing care of patients with these disorders.
MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with spinal cord disorders and CNS infections.
36) A college student is admitted for treatment of viral meningitis. What should the nurse expect to assess in this patient? Select all that apply.
1. Lethargy
2. Confusion
3. Photophobia
4. Neck stiffness
5. Positive Kernig sign
Page Ref: 1619
Cognitive Level: Applying
Client Need & Sub: Physiological Integrity: Reduction of Risk Potential
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 43.2 Describe the pathophysiology and manifestations of central nervous system infections, and outline the interprofessional care and nursing care of patients with these disorders.
MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with spinal cord disorders and CNS infections.
37) A patient with a chronic sinus infection is diagnosed with a brain abscess. What medication should the nurse expect to provide to this patient? Select all that apply.
1. Morphine sulfate
2. Digitalis (Digoxin)
3. Phenytoin (Dilantin)
4. Acetaminophen (Tylenol)
5. Broad-spectrum antibiotic
Page Ref: 1619-1621
Cognitive Level: Applying
Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning
Learning Outcome: 43.2 Describe the pathophysiology and manifestations of central nervous system infections, and outline the interprofessional care and nursing care of patients with these disorders.
MNL Learning Outcome: 2. Consider intraprofessional care for patients with spinal cord disorders and CNS infections.
Document Information
Connected Book
Medical Surgical Nursing 7e | Test Bank by LeMone, Burke, Bauldoff
By LeMone, Burke, Gerene Bauldoff
Explore recommendations drawn directly from what you're reading
Chapter 41 Assessing The Nervous System
DOCX Ch. 41
Chapter 42 Nursing Care Of Patients With Intracranial Disorders
DOCX Ch. 42
Chapter 43 Spine & CNS Disorder Care
DOCX Ch. 43 Current
Chapter 44 Nursing Care Of Patients With Neurologic Disorders
DOCX Ch. 44
Chapter 45 Assessing The Eye And Ear
DOCX Ch. 45