ATI Care of Patients with Problems of the Central Nervous System: The Spinal Cord, Questions and Answers with Explanations

1. The nurse is providing health education at a community center. Which instruction does the nurse include as part of client education for the prevention of low back pain?

a.	“Participate in a regular exercise program.”
b.	“Purchase a soft mattress for sleeping comfort.”
c.	“Wear high-heeled shoes only for special occasions.”
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.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology)

MSC: Integrated Process: Teaching/Learning

2. The nurse is caring for a client who has low back pain (LBP) from a work-related injury. Which measures does the nurse incorporate into the client’s plan of care?

a.	Apply moist heat continuously to the affected area.
b.	Use ice packs or ice massage for 1 to 2 hours over the affected area.
c.	Apply heat packs for 20 to 30 minutes at least four times daily.
d.	Advise the client to avoid hot baths or showers.

ANS: C

Heat increases blood flow to the affected area and promotes healing of injured nerves. However, continuous application of moist heat can promote skin breakdown.

DIF: Cognitive Level: Comprehension/Understanding REF: p. 962

TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Illness Management) MSC: Integrated Process: Nursing Process (Implementation)

3. A client who has a herniated disk is being discharged after a percutaneous endoscopic discectomy. Which postprocedure instructions does the nurse provide before discharge?

a.	“You should begin an exercise routine which includes walking every day.”
b.	“You must sleep in a supine position until the bandage is removed.”
c.	“You may feel numbness or tingling in the legs for 24 hours.”
d.	“You will need to wear a lumbar brace for 1 week.”

ANS: A

After this minimally invasive surgery, clients typically go home the same day or the day after surgery. Clients should be taught to begin the prescribed exercise program immediately after discharge, which includes walking every day. The client should not be restricted to one sleeping position. Clients generally have less pain with this procedure and do not experience numbness or tingling. The client may have a clear or gauze dressing but will not need to wear a lumbar brace.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications from Surgical Procedures and Health Alterations)

MSC: Integrated Process: Teaching/Learning

4. The nurse is assessing a client who had a discectomy 6 hours ago. Which client complaint requires priority action by the nurse?

a.	“I am feeling tired.”
b.	“My mouth is so dry.”
c.	“I can’t seem to relax and rest.”
d.	“I am unable to urinate.”

ANS: D

Inability to void may indicate damage to the sacral spinal nerves. The other symptoms require the nurse to provide care but are not the priority or a complication of the procedure.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications from Surgical Procedures and Health Alterations)

MSC: Integrated Process: Nursing Process (Analysis)

5. The nurse is providing discharge teaching to a client after a lumbar laminectomy. For which complication does the nurse instruct the client to return to the hospital?

a.	Pain at the incision site
b.	Decreased appetite
c.	Slight redness and itching at the incision site
d.	Clear drainage from the incision site

ANS: D

The finding of clear fluid on the dressing after a laminectomy strongly suggests a cerebrospinal fluid leak, which constitutes an emergency. The client has in increased risk of meningitis with a spinal fluid leak. Pain, redness, and itching at the site are normal. The client should be encouraged to eat a healthy diet but does not need to return to the hospital for a decreased appetite.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications from Surgical Procedures and Health Alterations)

MSC: Integrated Process: Teaching/Learning

6. The nurse is caring for a client who has undergone a spinal fusion. Which specific postoperative instructions does the nurse give this client?

a.	“You may lift items up to 10 pounds.”
b.	“Wear your brace when you are out of bed.”
c.	“You must remain on bedrest for 48 hours after surgery.”
d.	“You will need to take steroids to prevent rejection of the bone graft.”

ANS: B

Clients who undergo spinal fusion are fitted with a brace that they need to wear throughout the healing process (usually 3 to 6 months) whenever they are out of bed. The client does not need to remain on bedrest for the first 48 hours, should not lift anything, and will not take steroids for rejection prevention.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications from Surgical Procedures and Health Alterations)

MSC: Integrated Process: Teaching/Learning

7. A client who suffered a spinal cord injury at level T5 several months ago develops a flushed face and blurred vision. On taking vital signs, the nurse notes the blood pressure to be 184/95 mm Hg. Which is the nurse’s first action?

a.	Palpate the area over the bladder for distention.
b.	Place the client in the Trendelenburg position.
c.	Administer oxygen via a nasal cannula.
d.	Perform bilateral carotid massage.

ANS: A

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.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications from Surgical Procedures and Health Alterations)

MSC: Integrated Process: Nursing Process (Implementation)

8. Emergency medical services arrive to the emergency department with a client who has a cervical spinal cord injury. Which priority assessment does the emergency department nurse perform at this time?

a.	Level of consciousness and orientation
b.	Heart rate and rhythm
c.	Muscle strength and reflexes
d.	Respiratory pattern and airway

ANS: D

The first 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.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications from Surgical Procedures and Health Alterations)

MSC: Integrated Process: Nursing Process (Assessment)

9. The nurse is caring for a client who has a vertebral fracture. Which intervention does the nurse implement to prevent deterioration of the client’s neurologic status?

a.	Reorient the client to time, place, and person.
b.	Administer the Mini-Mental State Examination.
c.	Immobilize the affected portion of the spinal column.