Spinal Cord Injury (SCI)
Explain the difference between the two degrees of spinal cord injury: Complete and Incomplete.
Complete: TOTAL loss of sensory and motor function below the level of injury
Incomplete (partial): MIXED loss of voluntary motor activity and sensation - some tracts are still intact
The nurse teaches individuals that one of the best ways to prevent musculoskeletal injuries during physical exercise is by doing what?
A. Increase muscle strength with daily isometric exercise
B. Avoid exercising on concrete or hard pavement surfaces
C. Perform stretching and warm-up exercises before exercise
D. Wrap susceptible joints with elastic bandages or adhesive tape before exercise
C. Perform stretching and warm-up exercises before exercise
A client with RA tells the nurse, “I know it is important to exercise my joints so that I won’t lose mobility, but my joints are so stiff and painful that exercising is difficult.” Which of the following responses by the nurse would be most appropriate?
A. “You are probably exercising too much. Decrease your exercise to every other day”
B. “Tell the physician about your symptoms. Maybe your analgesic medication can be increased.”
C. “Stiffness and pain are part of the disease. Learn to cope by focusing on activities you enjoy.”
D. “Take a warm bath or shower before exercising. This may help with your discomfort.”
Answer: D. “Take a warm bath or shower before exercising. This may help with your discomfort.”
A nurse is caring for a client who injured her lower back during a fall and describes sharp pain in her back and down her left leg. In which of the following positions should the nurse plan to place the client to attempt to decrease her pain?
A. Prone without use of pillows
B. Semi-Fowler’s with a pillow under the knees
C. High-Fowler’s with the knees flat on the bed
D. Supine with the head flat
Answer: B. Semi-Fowler’s with a pillow under the knees
When planning care for a patient with a C5 SCI, which nursing diagnosis is the highest priority?
A. Risk for impairment of tissue integrity caused by paralysis
B. Altered patterns of urinary elimination caused by quadriplegia
C. Altered family and individual coping caused by the extent of trauma
D. Ineffective airway clearance caused by high cervical SCI
D. Ineffective airway clearance caused by high cervical SCI
A patient with a fractured right hip has an anterior open reduction and internal fixation of the fracture. What should the nurse plan to do postoperatively?
A. Get the patient up to the chair on the first postoperative day
B. Position the patient only on the back and the un-operative side
C. Keep the leg abductor pillow on the patient even when bathing
D. Ambulate the patient with partial weight bearing by discharge
Answer: A. Get the patient up to the chair on the first postoperative day
Teach the patient with fibromyalgia the importance of limiting intake of which foods (select all that apply)?
A. Sugar
B. Alcohol
C. Caffeine
D. Red Meat
E. Root vegetables
Answer: A, B, C
The nurse is conducting health screening for osteoporosis. Which client is at greatest risk of developing this disorder?
A. A 25 year old woman who runs
B. A 36 year old man who has asthma
C. A 70 year old man who consumes excess alcohol
D. A sedentary 65 year old woman who smokes cigarettes
Answer: D. A sedentary 65 year old woman who smokes cigarettes
A nurse is caring for a patient admitted with a spinal cord injury. The patient shows a complete loss of motor, sensory, and reflex activity below the level of injury. The nurse recognizes this condition as which of the following?
A. Central Cord Syndrome
B. Spinal Shock Syndrome
C. Anterior Cord Syndrome
D. Brown-Sequard Syndrome
B. Spinal Shock Syndrome
A patient with an extracapsular hip fracture is admitted to the orthopedic unit and placed in Buck’s traction. The nurse explains to the patient that the purpose of the traction is to do what?
A. Pull bone fragments back into alignment
B. Immobilize the leg until healing is complete
C. Reduce pain and muscle spasms before surgery
D. Prevent damage to the blood vessels at the fractured site
Answer: C. Reduce pain and muscle spasms before surgery
In teaching a patient with Systemic Lupus Erythematosus (SLE) about the disorder, the nurse knows the pathophysiology of SLE includes:
A. Circulating immune complexes formed from IgG autoantibodies reacting with IgG
B. An autoimmune T-cell reaction that results in destruction of the deep dermal skin layer
C. Immunologic dysfunction leading to chronic inflammation in the cartilage of muscles
D. The production of a variety of autoantibodies directed against components of the cell nucleus
Answer: D. The production of a variety of autoantibodies directed against components of the cell nucleus
A patient is being discharged after 2 weeks of IV antibiotic therapy for acute osteomyelitis in the left leg. Which information will be included in the discharge teaching?
A. The reason for taking oral antibiotics for 7-10 days after discharge
B. The need for daily aerobic exercise to help maintain muscle strength
C. How to monitor and care for the long-term IV catheter site
D. How to apply warm packs safely to the leg to reduce pain
Answer: C. How to monitor and care for the long-term IV catheter site
Which of the following clinical manifestations would the nurse interpret as representing neurogenic shock in a patient with an acute SCI?
A. Bradycardia
B. Hypertension
C. Neurogenic spasticity
D. Bounding pedal pulses
A. Bradycardia
What are the 5 P’s of compartment syndrome?
Answer: Pain, Pressure, Paresthesia, Pallor, Paralysis, Pulselessness
A nurse is providing information to a client who has osteoarthritis of the hip and knee. Which of the following information should the nurse include in the information? (Select all that apply).
A. Apply heat to joints to alleviate pain
B. Ice inflamed joints following activity
C. Install an elevated toilet seat
D. Take tub baths
E. Complete high-energy activities in the morning
Answer: A, B, C, E
When receiving discharge instructions, a patient with osteoporosis makes all of these statements. Which statement indicates to the nurse that the patient needs additional teaching?
A. “I take my ibuprofen every morning as soon as I get up”
B. “My daughter removed all of the throw rugs in my home.”
C. “My husband helps me every afternoon with range-of-motion exercises”
D. “I rest in my reclining chair every day for at least an hour”
Answer: A. “I take my ibuprofen every morning as soon as I get up”
The nurse is caring for a patient admitted over a week ago with an acute SCI. Which of the following assessments would alert the nurse to the presence of autonomic dysreflexia?
A. Tachycardia
B. Hypotension
C. Hot, dry skin
D. Throbbing headache
D. Throbbing headache
Correctly put the multistage fracture healing process (union) in the correct order:
A. Ossification
B. Remodeling
C. Fracture Hematoma
D. Granulation tissue
E. Callus Formation
F. Consolidation
Correct Order: C, D, E, A, F, B
A patient with rheumatoid arthritis is experiencing articular involvement. The nurse recognizes these characteristic changes include (select all that apply).
A. Bamboo-shaped fingers
B. Metatarsal head dislocation in feet
C. Noninflammatory pain in large joints
D. Asymmetric involvement of small joints
E. Morning stiffness lasting 60 minutes or more
Answer: B, E
A nurse is providing teaching for a client who has a history of low back injury. Which of the following instructions should the nurse give the client to prevent future problems with low back pain?
A. Engage in regular exercise including walking
B. Sit for up to 10 hours each day to rest the back
C. Maintain weight within 25% of ideal body weight
D. Create a smoking cessation plan
E. Wear low-heeled shoes
Answer: A, D, E