N4 - Test - CNS Probs

Ignatavicius & Workman: Medical-Surgical Nursing: Critical Thinking for Collaborative Care, 4th Edition

Chapter 43: Interventions for Clients with Problems of the Central Nervous
System: The Spinal Cord


1. A woman with lumbosacral pain tells you her personal habits include the following lifestyle activities. What should you instruct the client to avoid which may play a contributing factor to her back problems?

A. Playing tennis twice a week
B. Wearing high-heeled shoes daily
C. Taking the commuter train to work daily
D. Drinking two or three glasses of wine each weekend

2. For the client with lumbosacral pain who is being managed conservatively, which of the following actions should the nurse teach to reduce pain?

A. Stay on complete bedrest for at least one week.
B. Sit in a flat position with your legs fully extended.
C. Use a stool softener to avoid straining during defecation.
D. Drink at least three liters of fluids a day to prevent bladder complications.

3. You are caring for a client who has undergone spinal fusion. Which technique is correct for turning this client postoperatively?

A. Turn the client all at once with the back kept straight.
B. Turn the client’s lower body, followed by the upper body.
C. Using a turning sheet, move the client’s upper body before the lower body.
D. Place the client in position with the back arched forward, then proceed to turn the client.

4. Which of the following interventions will best assist the client with a spinal cord injury in preventing further deterioration in neurologic status?

A. Maintaining optimal body alignment
B. Assessing the bladder for fullness
C. Turning the client every two hours
D. Medicating the client for pain

5. The client, a 27-year-old male, fell from a second-floor balcony and has a spinal cord injury. Which function or assessment finding indicates an absence of immediate respiratory complications? The:

A. client is able to talk.
B. client is alert and oriented.
C. client’s oxygen saturation is 97%.
D. client’s chest and abdominal muscles are firm.

6. The client with a cervical spinal injury from an accident three hours ago is experiencing bradycardia and hypotension. Which of the following medications should you have prepared?

A. Methylprednisolone
B. Morphine sulfate
C. Atropine sulfate
D. Dextran

7. Which nursing intervention would be most beneficial in preventing complications associated with immobility for the client with a spinal cord injury?

A. Obtaining the client’s weight every day
B. Monitoring the client’s intake and output
C. Administering IV fluids to enhance hydration
D. Application of graduated compression stockings

8. What teaching instructions should be included for a client being discharged home with a Halo device?

A. “You should not drive while the Halo is in place.”
B. “Support the head with a pillow when sleeping.”
C. “Have a family member clean the pin sites.”
D. “Wear loose clothing.”

9. Which clinical manifestation would you expect a client with radicular pain from a spinal cord tumor to exhibit?

A. Burning pain accompanied by muscle spasms
B. Stabbing pain that is increased when lying flat
C. Pain is increased upon urination
D. Ptosis and bracheoplexopathy

10. Which statement regarding the pathophysiology of multiple sclerosis is true?

A. Nerve impulses are no longer transmitted.
B. Myocytes are damaged resulting in muscle weakness.
C. While the axonal body is involved, white fiber tracts are spared.
D. Damage to the myelin sheath results in an inflammatory response.

11. A client has been diagnosed with relapsing-remitting MS. What drug should you prepare to administer for continuous treatment of this disease?

A. Baclofen
B. Amitriptyline
C. Carbamazepine
D. Interferon beta-1a

12. You are preparing a client with MS for discharge following hospitalization for an exacerbation of the disease. Which instructions should be included in a teaching plan for this client?

A. Discontinue immunosuppressant drugs if symptoms improve.
B. Avoid extremes in temperature.
C. Space meals at least three hours apart.
D. Avoid physical exercise.

13. A client is suspected of having amyotrophic lateral sclerosis. Which early physical manifestations would you expect to see in this client?

A. Muscle atrophy
B. Fatigue while talking
C. Flaccid quadriplegia
D. Respiratory muscle failure